Transplant Patient Assistance

Contact Information

Name *

First

Last *

Last

Email *

Address *

Address

City

State/Province

Zip/Postal

Country

Phone Number *

Alt. Phone Number

Patient Information

Date of Birth (xx/xx/xxxx)

Sex *

Female

Male

Marital Status *

Married

Not Married

Number of people in patient's household? *

Are you the patient? *

No

Yes

Does patient need a transplant or have they already had a transplant

Needs a transplant

Has already had a transplant

Which organ?

Alternate Contact Info

Name

First

Last

Relationship to the patient

Email

Phone Number

Insurance Information

Do you have health insurance?

No

Yes

If yes, do you have Medicare?

No

Yes

If you do have Medicare, do you have Part D?

No

Yes

If yes to having part D, are you approaching the donut hole?

No

Yes

Doctor Information

Doctor Name

First

Last

Address

City

State/Province

Zip/Postal

Country

Phone Number

List medications you currently take

Income Information

What is your current household monthly income before taxes?

$0-$1000 a month

$1000 - $3000 per month

$3000 - $5000 per month

More than $5000 per month

Do you receive Social Security/Disability?

Yes

No

Do you receive unemployment?

Yes

No

Are you currently working?

Yes

No

Please briefly share what type of assistance is being requested *

Please tell us your story

Initials

By initializing below I certify that information provided is accurate to the best of my knowledge. I am providing Ava’s Heart with permission to verify information and rights to share my story to promote donations and awareness.

Transplant Patient Assistance

We provide patients, and their families, with housing pre and post transplant, co-payments on medications, insurance payments, gas cards for clinic appointments, emotional and psychological support and other resources and refuge.

From my new heart to yours,