Immediate Needs Fund – Request Form

The Employee Giving Committee accepts requests on Mondays and Wednesdays. Once an employee submits a request, they will receive a response within 72 hours of the request being reviewed.

Program guidelines

To assist patients/participants who do not have access to basic necessities that affect their health and well-being.
Those who do not qualify for this program:
  • AltaMed employees including: contractors, per diem, interns and/or AltaMed fellows
  • Family members of an AltaMed employee (including domestic partner, children, siblings, aunts, uncles, cousins, nieces, nephews, and/or grandparents)

Examples of eligible needs are:

  • Food & related items
  • Specialist appointment co-pay
  • Medication/Rx co-pay
  • Transportation to specialist appointment
  • Home essentials

Is this a Managed Care patient?

YES NO

Services and support are available for our managed care patients and can be accessed by sending a referral to the Medical Management Department. Below are examples of resources available through AltaMed Net:

AltaMed Net Instruction
• Community Based Adult Services
• Home Environment
• Low Income Utility Resources
• In Home Supportive Services (IHSS)
• Transportation
• Disability Resources
• Foundation Referrals
• Low Income Eye Glasses Resources
• Long-Term Services and Support (LTSS) / Multi-Purpose Senior Services Program (MSSP)
• Substance Abuse
• Food Resources
• Housing Resources
• Low Income Funeral Benefits Resources
• Mental Health
• SSI Benefits Information

Employee Information

This information is needed so that we can contact you if your request is approved.

PATIENT/PARTICIPANT INFORMATION

Please state an explanation or description of the need and the reasoning for requesting additional resources (DO NOT INCLUDE PATIENT NAME or any PHI). For example, patient needs assistance with groceries for the month.*

Please send any additional documents verifying need to [email protected]

PATIENT/PARTICIPANT NEEDS

Dollar amount requested: *







Dollars Distributed via: *


Has this patient/ participant been supported through the immediate needs fund in the past? *


Terms

SUBMIT

Thank you for your request!

Reminder, starting May 1 st , requests will be reviewed on Mondays and Wednesdays. You will receive a response within 72 hours of your request beginning the review process.

Thank you for your continued support and if you have any questions, please email us at [email protected]

If you have any questions, feel free to contact our Development Department by email at [email protected] or call us at (714) 495-0388.

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