info@jakeshelpfromheaven.org

Travel Reimbursement

Jake’s Help From Heaven welcomes applicants of all ages living within 100 miles of Saratoga Springs, NY.

Jake’s Help From Heaven looks to help individuals and families impacted by complicated medical lives and challenges. We provide reimbursement for medical travel to see doctors, specialists and/or to have procedures. Please use this: JHFH TRAVEL APP 2024

The expense report portion of  our application is also available as an EXCEL document. Please feel free to use this and it will do the math for you!

If you need additional worksheets to print out, you may download them here:Medical Travel Worksheet

Grant Eligibility:
• Grants are limited to individuals living within 100 miles of Saratoga Springs, New York.
• Grants are restricted to individuals with complex medical needs and disabilites resulting from
congenital or childhood-onset diseases. Applicants of all ages with lifelong, debilitating illnesses
are welcome to apply.

AS OF 2024, 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.
• There is a $2,500 cap per applicant per calendar year. Applicants may apply multiple times
within a calendar year but are only eligible to be awarded a total of $2,500 within that year.
• If you receive your requested item 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.

IN ADDITION, PLEASE NOTE THE FOLLOWING POLICY CHANGES:

• 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.
• Applicants requesting a grant of over $1,000 may be asked to submit a current income tax return
or other financial information.
• 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: 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.

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: 2 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: 2 MB.
    Printed name of social worker or primary doctor(Required)
    MM slash DD slash YYYY