3112 Clearwater Drive, Suite A • Prescott, Arizona 86305
(Phone) 928.776.4612 (Fax) 928.771.1767
STRMU
Financial Assistance
Request
Client ID: _________________________________________ Date of Request: ________________________________
B
y submitting this form the case manager attests that the client is RW eligible and declares there are no other funding
sources to assist client with payment; making RW the payer of last resort.
F
unds to be issued as follows:
1. Name:_____________________________________________ Amount: $__________________________
Address: __________________________________________ Payer Source:
____________________________________________________
2
. Name:_____________________________________________ Amount: $__________________________
Address: __________________________________________ Payer Source:
____________________________________________________
3
. Name:_____________________________________________ Amount: $__________________________
Address: __________________________________________ Payer Source:
____________________________________________________
Notes: ____________________________________________________________________________________________________________________________
Director Signature of Approval: __________________________________________________________________ Date:______________________
C
opies of all payments must be attached to request and filed in client case management file
Circumstances of Request:
Case Manager Signature: _____________________________ Date:____________________
Provider Verification (for medication requests only):
Provider Signature:_____________________________________ Date:__________________
Income Eligibility on file? Yes NO Household Size:_______________
AMI for Household: _________________ (Monthly x12)_____________________(annual)
Established 80% of AMI_______________________for___________________________County
HOPWA Case Manager Signature:_________________________________ Date:________________________________
*Case Manager has obtained documents of income for each individual that comprises the household that is requesting financial assistance and certifies that this
individual or household is at or below the 80% Area Median Income Guidelines for the county of residence.
Attachment 27
