Namaste Comfort Fund - Assistance Form

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Namaste
Comfort Fund
(303) 860-9915
fax: (303) 860-9914
1633 Fillmore Street
Suite 300
Denver, CO 80206
Email

NOTE: Please review all assistance criteria, exclusions, and conditions prior to completing application. Please provide all information as completely as you can. Personal and medical information requested on patient-recipients is for confirmation of criteria and internal tracking purposes only and will be held in strict confidence. If you have questions, call 303-860-9915, and ask for the Namaste Comfort Fund Executive Director.

Has this person or his or her authorized agent or guardian granted consent to your making this request and disclosing relevant medical and personal information? Yes No (Note: Consent is required!)
	Regular Request (7 to 10 days to process) OR
	Urgent Request (48 hours to process)
Applicant's First Name:
Applicant's Last Name:	("Applicant" is the person completing this form - must be a health care, human service, or pastoral professional.)
Title:
Organization:
Address:
Apt./Suite:
City:
State:
Zip:
Phone:
Pager/Cell/Other (specify):
E-Mail:
Person for whom request is being made:	(Patient or immediate family caregiver.)
What is this person's: Age: Sex: Male Female Race:
Does this person have: Private insurance Medicare Medicaid No insurance Don't know
What is this person's diagnosis/condition?
In what city does this person live?
Assistance request is for (specify item or service):
	This is a one-time request OR
	This request is for an ongoing service of: (# of) days weeks months (choose one)
Exact amount requested:	(Provide exact, documented purchase price of items or all applicable costs of services.)
Amount to be paid to:
Requests for retail items less than $100 will be paid as reimbursements to individuals. Following approval of application, submit an explicit receipt showing date and location of purchase, item, and cost. If item will cost more than $100.00 or if request is to cover an ongoing service, an invoice from the point-of-purchase company or service provider must be submitted.
In your own words, please tell us how this item or service will enhance the patient’s comfort or quality of life and describe other resources you have explored prior to making this request. Please use as much space as needed.