Financial Request Form

 

 

                     

All requests are to be reviewed and approved by the referring Lay Health Advisor, where applicable, and mustbe signed by Belinda Hill Jones, Pink Link Project Coordinator.  All approved requests will be processed by the Gregory B. Davis Foundation’s Chief Operations Officer within 24-48 hours of receipt.

Financial Assistance to requesting individuals will be provided in limited amounts based upon availability.

 

This includes areas such as:

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• Gas Card ($25)

• Support for Child Care

• Co-Pay—Clinical Diagnosis and Treatment

• Food/Per Diem for Office Visit exceeding 20 miles one-way

• Lodging (Clinical Diagnosis)

• Lodging (Clinical Treatment)

 

You are to complete this entire form.  All requests must be signed the Patient Navigator/Referral Source before submission to funding agent, Gregory B. Davis Foundation.  Must submit a separate form for each request.  Please allow 24 hours for a response. Requests can be emailed to rvbccpinklink@gmail.com  or a photo of the form can be sent to (252) 678-2249.     

                      

Questions??? Please call (252) 678-2249 

 

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