Family Assistance Reimbursement Claim Form

Please submit this form for each clinic visit or hospitalization that you are wishing to be reimbursed for. The Vivian Lee Foundation will confirm this with your doctor's office. Please also submit any receipts for childcare that was provided for this appointment.

Patient Name Patient Name First Last
Clinic appointment date or First date of hospitalization Clinic appointment date or First date of hospitalization / MM / DD YYYY
Number of days in hospital
Clinic or Hospital Name:
Name of Physician Treating the Patient for CF Name of Physician Treating the Patient for CF First Last
What type of chidcare did you use for this appointment?

What type of chidcare did you use for this appointment? Family Member Babysitter/Nanny Childcare Center/School
Name of childcare provider
Childcare Provider Phone Number Childcare Provider Phone Number - ### - ### ####
How many hours of childcare did you need for this appointment? Please consider travel to and from the hospital, and duration of appointment.
Did any parent have to take time unpaid time off of work for this appointment or hospital stay?

Did any parent have to take time unpaid time off of work for this appointment or hospital stay? Yes No
Name of Employer
Employer Phone Number Employer Phone Number - ### - ### ####
Please state the amount of income lost or childcare paid for this appointment.
Family Assistance Program Guidelines

The Family Assistance Program by the Vivian Lee Foundation has the following limits per family (special circumstances will be evaluated by the Foundation on an individual basis).

-Each family can be reimbursed up to 4x per calendar year.
-A maximum daily amount per appointment is limited to $15/hour for 8 hours.
-Hospitalization benefits will be evaluated on an individual basis.
Signature & Acknowledgment

By submitting this form, I hereby authorize the Vivian Lee Foundation to obtain my protected health information. This medical authorization hereby authorizes your medical provider to speak with Vivian Lee Foundation and have access to all your medical records on your child. The authorization is obtained for this transaction only. The authorization expires when this transaction is complete.

I verify that the information provided in this application is complete and accurate. I also understand the Vivian Lee Foundation reserves the right at any time and without notice to modify the assistance and discontinue any or all of the programs and related eligibility criteria at any time.
Draw your signature into the box below.

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Family Assistance Reimbursement Claim Form

Family Assistance Reimbursement Claim Form

Family Assistance Program Guidelines

Signature & Acknowledgment