Assistance Request Form - Dr. Theodore A. Atlas Foundation

Use this form to request assistance from the Foundation. The following request for assistance contains detailed questions about your insurance and financial status. Please have your financial information on hand before beginning.

Theodore A. Atlas Foundation Request for Assistance

Date of Request

Referred By

Personal Details

Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Home Phone *

Cell Phone

Email Address *

Employment & Insurance

Employment *Are you currently employed?

Employer Details *Name & Address of your employer

Marital Status

Insurance CoveragePlease enter the name of your insurer, if applicable

Have you ever received assistance from the Foundation? *

Is your request for assistance based on the follow? *Medical NeedsFinancial NeedsOtherCheck all that apply

Additional Documentation

Documents

PROVIDE COPIES OF PAYROLL STUBS AND/ COPY OF YOUR VALID DRIVER’S LICENSE/PHOTO ID.

Email to info@dratlasfoundation.com

PLEASE EMAIL A LETTER STATING IN DETAIL THE REASON FOR YOUR REQUEST AND INCLUDE ALL PERTINENT DOCUMENTATION (i.e. MEDICAL INFORMATION, ESTIMATES ON COSTS OF MEDICAL EQUIPMENT) SUBSTANTIATING YOUR REQUEST SO THAT THE ATLAS FOUNDATION CAN REVIEW YOUR REQUEST THOROUGHLY AND PROMPTLY.

Be sure to mention in your email that the documents are for this application. Include your name, phone number, and email address in case we need to follow-up with you.

Or type your letter below. (Documentation must still be uploaded)

Information About RequestPLEASE GIVE DETAILED INFORMATION OF YOUR GRANT REQUEST