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APPLICATION FOR FUNDING Initial Application Powered By Docstoc
					                                                                       APPLICATION FOR FUNDING
                                                     _____ Initial Application                                       _____ PT
                                                     _____ Re-Application                                            _____ OT
                                                                                                                     _____ SP

      Post Office Box 71627                      Attached:
      Phoenix, Arizona 85050-1627                Most recent evaluation                        Most recent tax return                     
                                                 Most recent progress notes                    Recent child’s photograph              
PURPOSE: To provide partial funding to those families in need of financial support for their child’s therapy services (physical, occupational,
and speech-language therapy). Funding is for families with children between the ages of birth through twelve years, living in Maricopa
County, Arizona, who have depleted their current insurance and/or are waiting on state subsidized funding or an alternative source. This
funding is not to exceed $35.00 per hourly session, $20.00 per 1/2-hour session or 50% of that amount which is not covered by the
insurance carrier. No more than two therapy sessions will be funded per week unless special circumstances are brought to the Board for
review. Group therapy sessions, if approved, will be funded at lower rates.
Complete all fields to avoid processing delays.
Child’s Name ________________________________________ Date of Birth __________________
                                                                                                 (age cannot exceed child’s 13 birthday)
Parents or Legal Guardian ___________________________________________________________
Address ___________________________________ City _________________ Zip code _________
Phone #: Home _____________________________Work _________________________________
Mobile: _________________________                         Email address (if applies): __________________________
Family’s Annual Gross Income: (eligibility requires that income not exceed $100,000 / year)
 Less than $10,000                  $10,000 - $40,000                   $40,000 - $65,000                  $65,000 - $100,000
                         Verification of income is requested by CITT. Please attach most recent tax return.

Are you currently receiving funds from any organization/insurance companies?                                    Yes  No
If yes, from whom & how much? : _____________________________________________________

Briefly state why you need subsidy for your child’s therapy:

Agency providing the service: ______________________ Phone # __________________________
Therapist: _____________________________________ Phone #___________________________

Is this an in-network provider?            Yes  No
If No, what are your out-of-network benefits? ____________________________________________
What is the frequency of your child’s therapy? _________ sessions per [circle one:] WEEK                                      MONTH
Is the therapy session: [circle one:] ONE-TO-ONE                       GROUP [circle one:]           1 HOUR           1/2 HOUR
What is the total charge for each of your child’s therapy sessions or evaluation? $________________
What amount of this charge do you personally have to pay? $________________________________
What amount of money per therapy session or evaluation are you requesting from CITT? $__________
                                                                          Application continues on reverse side (page 2)

      If applying initially, please attach a copy of the most recent therapy evaluation (including short term
       measurable goals) that states the reasons for your child’s need for therapy services.

      If reapplying, please attach a copy of the current progress report.

      Please send a photograph of your child with your application for use in fund raising events.

The services rendered are the matter of contract solely between the applicant and provider. It is the
applicant’s responsibility to insure that the services contracted have been properly rendered and
Initials: ____

The applicant agrees that once approved and funding provided, that CITT, in its sole discretion, might
obtain medical records pertaining to the services rendered for the purpose of reimbursement and/or for
the purpose of insuring compliance with the provider agreement and contract on file.
Initials: ____

Your application will be reviewed by CITT and you will be notified by mail of the decision. Please address
questions to the P.O. Box only. In signing this form, you agree that any necessary financial or treatment
information may be released to CITT.

CITT certifies that we will not give/lend information provided in this application or therapy reports to other
organizations or persons not relevant to needs beyond reimbursement and enforcement of provider
agreement and contracts.

Signature of Parent or Guardian_______________________________________ Date____________

       Revised 1/2004

Description: Arizona State Tax Return Forms 540 document sample