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MFG HEALTH FREE CARE FUND APPLICATION
FIRST NAME _________________________________________________________
MIDDLE NAME________________________________________________________
LAST NAME __________________________________________________________
SOCIAL SECURITY NUMBER ____________________________________________
ADDRESS ____________________________________________________________
CITY _________________________ STATE ____________ ZIPCODE____________
TELEPHONE _________________________________________________________
DESCRIPTION OF YOUR CHRONIC AILMENTS:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
* PRIMARY CARE PHYSICIAN NAME ____________________________________
ADDRESS ____________________________________________________________
CITY _________________________ STATE ____________ ZIPCODE____________
TELEPHONE _________________________________________________________
* MASSAGE THERAPIST NAME _________________________________________
ADDRESS ____________________________________________________________
CITY _________________________ STATE ____________ ZIPCODE____________
TELEPHONE _________________________________________________________
* YOUR INSURANCE CARRIER NAME ___________________________________
ADDRESS ___________________________________________________________
CITY _________________________ STATE ____________ ZIPCODE____________
TELEPHONE _________________________________________________________
POLICY NUMBER _____________________________________________________
GROUP NUMBER _____________________________________________________
PRIMARY INSURED NAME ____________________________________________
YOUR RELATIONSHIP TO PRIMARY INSURED _____________________________
All information we receive will be held
strictly confidential per federal HIPAA regulations.
We can assist you in finding a qualified
massage therapist if you do not currently
receive treatment.
Print out this application and send it to:
Massage For Good Health Foundation,
ATTN. DAWN LEONE,
98 Oakridge Drive, Indiana, Pennsylvania 15701,
mfghealth@hotmail.com
MFG Health Home Page
