Family Support
Application for Assistance
Craniofacial Centers
International Visiting
Professor Team
Fellowships
Patient Education
|
|
•
•
•
Please fill out application completely, sign the photo release and consent release at the end of the application (last 2 pages of application) and include the following items:
- A recent photograph of the patient. Photograph will not be returned.
- A copy of any medical records/information on the patient.
- A letter from attending physician, confirming appointment date, treatment plan and estimated length of stay.
- A copy of your most recent IRS tax return.
- A copy of your most recent check stub.
Send your application to the WCF.
Prior to receiving WCF Family Care support:
- Applicant must complete and return request for assistance four to six weeks in advance of the date of travel. Medical emergency will be the only exception and declaration of emergency must come in writing from attending plastic surgeon and/or PCP/ pediatrician.
- Applicant must provide letter from attending plastic surgeon, confirming appointment date, surgical treatment plan/procedures and estimated length of stay.
- Applicant must provide attending plastic surgeon and PCP/pediatrician's name and contact information.
- Applicant must sign release of medical information form to the WCF in accordance with HIPPA.
- Applicant must provide with completed application a copy of their IRS return (this may not apply out of the U.S.) and copy of their most recent check stub.
- Applicant must sign WCF photo release form and provide pre and post operative photos of patient.
- Applicant must provide medical history/records on the patient.
|
Application for Assistance