Apply for a grant

Are you over the age of 50 *

Do you reside in Kern County? *

Applicant Information

Name *

First

Last

Phone *

Email *

Date of Birth *

MM-DD-YYYY

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pharmacy own household

How many people are currently living in your household? *

What is your total annual household income before taxes? *

Less than $20,000
$20,001 - $40,000
$40,001 - $60,000
$60,001 - $80,000
Over $80,001

Grant Category Selection

Please select the type of grant you are applying for: *

Transportation Support (Gas Cards)
Medical Bill Assistance

Treatment Information

Provide details about your healthcare providers and treatment.

Hospital/Institution Name *

Primary Doctor/Treatment Provider Name *

Pharmacy Name *

Other Relevant Treatment Information (optional) *

Insurance Details

If you have coverage, provide your insurance information below.

Insurance Provider Name *

Policy Number *

Did you apply to Medi-Cal? *

If "yes," were you denied? *

Financial Information

Employment Status *

Employed
Retired

Condition Duration

How long have you been managing heart failure? *

Insurance Premium *

Be sure to share the payee and monthly cost

Medications *

Doctor’s Visits *

Be sure to share the payee and monthly cost

Other (Specify) *

Be sure to share the payee and monthly cos

Please upload any supporting documents to verify your financial situation and medical expenses. This may include your most recent tax return, medical bills, and invoices related to heart failure treatments.

Click or drag a file to this area to upload.

Applicant Narrative

In your own words, describe your journey with heart failure and how this grant would help you.

Applicant Certification & Signature

I confirm that all information provided in this application is complete, accurate, and truthful to the best of my knowledge. I acknowledge that any false or misleading information may result in disqualification from receiving assistance. By checking this box, I agree to these terms and understand that my submission constitutes my acknowledgment and acceptance of this statement.

Do you agree *

I agree
I disagree

Ensure all sections of the application are completed. Submit this application and await a response. Grants are reviewed and approved monthly.