Financial Assistance Due to Hospital Stays

Application for Financial Assistance

PLEASE READ THIS BEFORE APPLYING!!

This application is to be filled out by the parents or guardian when financial assistance is needed due to pregnancy complications and/or NICU stays.  Applications that are filled out by the social worker alone will need additional documentation from the parents stating their compliance in the application. 

  • 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.

With this application, you also 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.  

  • Additionally, if you leave the information about income blank or with unsure or unknown, we will not process the application until you provide us with this information.  You can provide an estimate if you do not know exact amounts.

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.

  • For a special note, if you are applying for assistance with medical bills related to pregnancy hospitalization, delivery, and/or NICU stay and treatment for child in the hospital, 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.)

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.

 

 

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