Local Travel Form | Jake's Help From Heaven

Jake’s Help From Heaven LOCAL Medical Travel Application

Jake’s Help From Heaven was founded in 2011 by Jake’s parents, Brian and Heather Straughter. Jake Alexander Straughter earned his angel wings on December 8, 2010. Jake was born on May 4, 2006 a healthy, vibrant baby boy. He suffered a seizure at 8 months old and this began his very complicated medical journey. Through his short life, he battled epilepsy, liver disease, osteopenia, femur fractures, hip dislocation and more. He faced each hurdle with strength and courage and taught those around him how to persevere. Though Jake lived in Saratoga Springs, NY, the majority of his care took place in Boston, MA. With rare and severe illnesses, we understand the importance of seeking medical care from the best specialists at top hospitals.

This LOCAL Medical Travel Application is intended for those who travel less than 90 miles for their medical care. This application is for medical care outside the scope of routine visits with a pediatrician or primary care physician. Reimbursement is provided only for mileage and only for care that relates specifically to the applicants’ diagnosis.
Grants will be awarded up to $2500 per calendar year. Applicants can apply more than once but for not more than $2500 per calendar year.
Grants will be reviewed by the Board of Directors four times per year and grants will be awarded following these meetings. Deadlines for each meeting are posted on our website at jakeshelpfromheaven.org
All Jake’s Help From Heaven applicants must live within 100 miles of Saratoga Springs.

*Please note that even if you are a REPEAT APPLICANT, you must fill out a MEDICAL TRAVEL APPLICATION in order to be reimbursed for your medical travel*

TRAVEL APPLICATION GUIDELINES – Please complete all Sections

Section A- Personal Information

To be completed by patient or legal guardian. Please provide all personal contact information. Provide a brief description of the medical treatment. If necessary, attach a separate sheet with your explanation.

Section B-Medical Treatment/Services Information

List the name of the facility you will be traveling to and include the facility address and telephone number.
A post appointment letter from the treating doctor indicating reason(s) for treatment and treatment date(s) is REQUIRED. Attach this letter as a part of your application.

Section C-Travel Information

Provide the date and total mileage for each appointment on the worksheet provided. Mileage is paid at .40 per mile. This rate is inclusive of all related transportation expenses. We do NOT reimburse for any parking or tolls. We do NOT reimburse for gas.

Section D-Disclosure/Signature

Date and sign the application. Must be signed by medical doctor and/or social worker as well.

Incomplete applications will result in a delay or denial.

Jake’s Help From Heaven LOCAL Medical Travel Application

Section A: Personal Information

Applicant Name:(Required)

First Last

Age:(Required)

Please enter a number less than or equal to 130.

Parent/Guardian (if applicable):

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Describe your medical condition and the treatment you are seeking. Include your current treatment plan and the frequency of your medical appointments.(Required)

Section B: Medical Treatment/Services Information

Doctor(Required)

First Last

Facility:(Required)

Facility Address(Required)

Street Address Address Line 2 City State ZIP Code

Doctor's Phone(Required)

Post Appointment Letter(Required)

Max. file size: 2 MB.

Section C: Travel Information

Travel Expense Worksheet

Expense Worksheet(Required)

Max. file size: 2 MB.

Section D: Disclosure/Signature

Disclosure(Required)

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 to enable travel for medical treatment/services.

Disclosure(Required)

I understand that I may be required to provide additional evidence of submitted information and I give permission to Jake’s Help From Heaven to contact the medical facility for verification purposes.

Disclosure(Required)

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)

First Last

Signature of Applicant or Parent/Guardian(Required)

Date(Required)

Printed name of social worker or primary doctor(Required)

First Last

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.

Social worker or Primary Doctor Signature

Max. file size: 2 MB.

Signature of social worker or primary doctor

Date(Required)

Contact Phone number or email(Required)

Phone

This field is for validation purposes and should be left unchanged.