Additional Information | The Gregg Pearson Foundation

Thank you for submitting a Request for Assistance from our website. We are so sorry to hear about your illness and know this is an extremely difficult time for you.

In order to process your request, we will need some additional information. Can you please provide the following?

NAME

Your Name*

First Last

(Sorry, we know we have already asked for this but we need to match this additional information to your original request. Having your name ensures we match the two submissions correctly.)

Email*

Patient's Name*

First Last

(Sorry, we know we have already asked for this but we need to match this additional information to your original request. Having your name ensures we match the two submissions correctly.)

Please upload your diagnosis verification (PDF preferred) - 3 files maximum*

Drop files here or

Accepted file types: pdf, doc, jpg, png, Max. file size: 1 GB, Max. files: 3.

Do you or the patient have insurance coverage?*

Are you or the patient being supported financially by any other organizations? If so, provide details.*

Are there plans or has there been a fundraiser on the patient's behalf (i.e. GoFundMe)?*

Do you or the patient have a faith background to help you/them handle this difficult situation?*

Do you and the patient have a church home?*

If so, can we partner with them? Please provide contact name and number.

Do you or the patient have family support both financial and emotional?*

What is the biggest need right now: emotional, spiritual or financial?*

If financial, please list what the specific needs are and the amounts (i.e. $1500 rent, $250 utilities, $250 car payment).

(Since we are a small foundation, we are not able to pay medical bills, copays or prescriptions)

Moving forward, what will be your source of income for the months ahead?*

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