Apply
Start with eligibility.
The full secure application portal is being prepared. This page is already structured for the eventual intake workflow, but it is intentionally not collecting sensitive medical or financial documents yet.
Website preview: The form below is not connected to a database, email inbox, or Google Drive yet. Do not submit sensitive information until the secure application workflow is activated.
Preliminary eligibility preview
What the full application will request
Only what is reasonably necessary.
- Basic applicant and eligible-patient contact information.
- Limited documentation confirming the qualifying surgery.
- Household income, household size, and recovery-related financial circumstances.
- Description and amount of the requested assistance.
- Relevant invoices, estimates, bills, or receipts.
- Information about insurance or other assistance where relevant.
The Foundation does not intend to request complete medical records when more limited documentation is sufficient to establish eligibility.