This is what we will be asking for:

• Applicant Information. Name, address, email, phone number(s).
• Personal Representative Information. If applicable, contact information for the person completing the form if not the applicant/patient.
• Care Provider Information. Name, phone number, and dates of service of the Christian Science nurse or facility.
• Financial Information. Amount of the request, explanation of what you can contribute, other sources of funding, approximate net worth. (A worksheet for your personal use is available. Click on the button below to access the net worth calculator worksheet.)
• Documentation. Standard Authorization Form, Federal tax form 1040 (first two pages only), Power of Attorney (if applicable), CS nursing and practitioner invoices (may be submitted later).

After we speak with you and have all necessary documentation, we will strive to have an answer within 3 business days. During the initial launch of the fund, the response time may be longer—5 to 10 business days.

All information you provide will be kept in strict confidence.