info@jakeshelpfromheaven.org

Travel Reimbursement

Jake’s Help from Heaven, founded in 2011, is a non-profit that creates opportunities for those with complex medical challenges and physical disabilities to thrive.

 

Effective as of June 19, 2024, Jake’s Help from Heaven has adjusted our mission and made some policy changes to ensure the sustainability of our organization.  Please review our new standards carefully.  We are committed to continuing to make a difference in the lives of those who need us for as long as we can, while also staying true to our roots.

Grant Eligibility: 

  • Grants are limited to individuals living within 40 miles of Saratoga Springs, New York.
  • Grants are restricted to individuals of any age with complex medical needs and physical disabilities resulting from congenital or childhood-onset
  • There is a $1,500 cap per applicant per calendar year.
  • Priority is given to repeat applicants.

INCOMPLETE APPLICATIONS WILL NOT BE SUBMITTED TO THE BOARD OF DIRECTORS FOR CONSIDERATION. THE FOLLOWING CRITERIA MUST BE MET:

  • A post-appointment letter or complete discharge notes from the treating doctor indicating reason(s) for treatment and the treatment dates.
  • Completed Expense Worksheet with all columns totaled.
  • Completion of the following application with the signature of a pediatrician/primary care doctor, social worker, or care worker.
  • Receipts for reimbursement.
  • To be eligible for reimbursement, the travel must have taken place within one year of the date that the application is being reviewed.
  • Applicants should submit their completed applications with all required documents at one time, and not in separate pieces.
  • Electronic applications must be submitted in PDF format. We DO NOT accept jpegs or screenshots.
  • If you receive your requested funds elsewhere, please alert us immediately so that we can withdraw your application. Failure to do so may affect your eligibility to apply in the future. 
  • Please double-check that the applicant’s address is listed correctly. JHFH is not responsible for replacing reimbursements mailed to the wrong address due to errors on the application.
  • When individuals other than the applicant are completing the application, please write in the third person and do not write in the applicant’s voice.

Jake’s Help From Heaven Medical Travel Application 2024

Section A: Personal Information

Applicant(Required)
Please enter a number from 1 to 150.
Parent/Guardian (if applicable)
Address(Required)

Section B: Medical Treatment/Travel Information

Please fill out the attached Expense Worksheet COMPLETELY. This includes totaling all appropriate columns. Applications will not be reviewed if this sheet is not filled out.

Facility Address(Required)

Completed expense worksheet is REQUIRED. You may upload your documents here or mail your documents in.

Download the Expense Worksheet as an EXCEL file or PDF
Accepted file types: jpg, pdf, Max. file size: 768 MB.

A post appointment letter or complete discharge notes from the treating doctor indicating reason(s) for treatment and treatment dates is REQUIRED. You may upload your documents here or mail your documents in.

Accepted file types: jpg, pdf, Max. file size: 768 MB.

Receipts for reimbursement are REQUIRED. You may upload your documents here or mail your documents in.

Drop files here or
Accepted file types: jpg, pdf, Max. file size: 768 MB.

    Section C: Disclosure/Signature

    I declare that the information provided on this application for financial assistance is true and complete to the best of my knowledge. I understand that what I submit to Jake’s Help from Heaven is for the purpose of financial reimbursement or direct purchase of medically necessary or convenient items and services. I understand that I may be required to provide additional evidence of submitted information, including a current income tax return or other financial information. I give permission to Jake’s Help from Heaven to contact the provided medical facility for verification purposes. I agree to allow Jake’s Help from Heaven to use my name in announcements and related publications.
    Printed name of Applicant or Parent/Guardian(Required)
    MM slash DD slash YYYY

    You may upload a photo or a scan of a signed document from your doctor with the endorsement saying "I (social worker or primary doctor) support (applicants name) application for (requested item) on (date)” or use the save and continue option and send your social worker or primary doctor the link for them to sign. After adding their signature, your doctor or social worker must then use the save and continue option and send you the new link to your form.

    I support (applicants name) application for (requested item) on (date)”
    Accepted file types: jpg, pdf, Max. file size: 768 MB.
    Printed name of social worker or primary doctor(Required)
    MM slash DD slash YYYY