Jazz Project Medical Fund Application

Name:                                                                                                                        

Address:                                                                                                                    

Phone/e-mail                                                                                                              

Instrument(s)                                                                                                             

Injury/Medical Treatment sought                                                   

Explain your primary funding request or attach information

1. Emergency Medical  Bills:                                                          

2. Rehabilitation Bills:                                                                      

3. Office Visits and follow-up medical                                            

            Amount Billed:                                                       $______

            Amount covered by insurance, if applicable $______

            Balance owing:                                                      $______

            Amount previously paid out of pocket:           $______

            Amount able to pay toward balance:                      $______

            Funding request:                                                   $______

Have you attached a copy of the bill for which you are requesting assistance?

Yes                  No                  
       

Funding Approval: (Jazz Project use only, do not complete)

____Yes, fund request in full

____ Fund partial request $                 

____ Funding not available at this time

_____________________                          ____________________

Jud Sherwood, Jazz Project Director          Date