Test Applications

Jake’s Help From Heaven Medical Travel Application

Section A: Personal Information

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

Section B: Medical Treatment/Services Information

Facility Address(Required)

Section C: Travel Information

Please fill out the Expense Worksheet COMPLETELY. This includes totaling all appropriate columns. You may upload your documents here or mail your documents in. You may upload your documents here or mail your documents in.

Accepted file types: jpg, pdf, Max. file size: 2 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: 2 MB.

Section E: 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 to enable travel for medical treatment/services. 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. 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. they would then need also use save and continue later and send back the new link to your form

I support (applicants name) application for (requested item) on (date)”
Printed name of social worker or primary doctor
MM slash DD slash YYYY