Financial Assistance Due to Hospital Stays

Application for Financial Assistance

PLEASE READ THIS BEFORE APPLYING!!

This application is to be filled out when financial assistance is needed due to pregnancy complications and/or NICU stays.  The financial assistance provided is to pay bills either on a one-time basis or on a longer basis.  Some of the types of bills we have covered are rent/mortgage, utilities, childcare, transportation costs, car payment, car insurance, transportation costs, phone bills.

  • Please list the bills you need assistance with and the estimated amount.  We will need documentation of the bills in order to process payment--you can upload those on the application or upon initial approval of the grant.
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  • If you are applying for assistance with medical bills, you will need to share what the medical bills were for and what steps you have taken to defer the costs (i.e. applied for financial assistance, entered a payment plan, etc.)

With this application, you need to provide some sort of verification for the hospital and/or NICU stays from the hospital, whether that be the form that we have provided here or another similar form.  We need both things before we will review the application.  We review applications on a weekly basis and respond appropriately.

If you have questions or want to submit additional information, you can e-mail us at michelle@colettelouise.com.

Please  note that submitting an application does NOT guarantee payment or issuance of a grant.  The Colette Louise Tisdahl Foundation will make decisions on a case by case basis and ultimately retains the right to decide when and how much money will be issued to each family.

 

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