Healthcare Foundation Patient Assistance Application

Help Patients Access Critical Medical Care with a Streamlined Assistance Fund Application

For healthcare foundations and nonprofit medical organizations, providing financial assistance to patients in need is core to your mission—but managing applications efficiently while maintaining patient privacy can be challenging. This Healthcare Foundation Patient Assistance Application template from Paperform gives you a professional, compassionate way to collect patient information, assess financial need, and allocate support fairly and transparently.

Built for Healthcare Foundations and Patient Assistance Programs

Whether you're running a hospital foundation, disease-specific nonprofit, community health center, or charitable clinic, this template helps you:

• Gather complete patient and financial information through a structured, easy-to-follow application
• Assess financial need consistently with income verification, expense documentation, and household information
• Maintain organized records of all applications for review, approval workflows, and reporting
• Respect patient dignity with a professional, compassionate form design that puts applicants at ease

The form walks applicants through personal information, medical needs, financial circumstances, insurance coverage, and supporting documentation—giving your review committee everything needed to make informed, equitable funding decisions.

A Note on HIPAA Compliance

While this template is designed with healthcare privacy best practices in mind, Paperform is not a HIPAA-compliant platform. If your organization is a covered entity under HIPAA and you need to collect Protected Health Information (PHI), you'll need to implement additional safeguards such as using a HIPAA-compliant form solution or collecting sensitive medical details through secure offline channels.

This template is best suited for foundations and charitable organizations that are not directly covered entities, or as part of a broader process where sensitive PHI is handled through compliant systems. Always consult with your legal and compliance teams to ensure your patient assistance application meets all regulatory requirements.

Designed for Compassion and Clarity

Applying for financial assistance can be stressful for patients and families already facing medical challenges. This form template is structured to:

• Guide applicants step by step through required information without overwhelming them
• Explain each section clearly so patients understand why information is needed
• Allow document uploads for pay stubs, tax returns, medical bills, and insurance statements
• Provide immediate confirmation with next steps and expected timelines

The professional, accessible design ensures applicants feel respected and supported throughout the process—reinforcing your foundation's commitment to dignity and care.

Streamline Review and Approval with Automation

Once applications are submitted, Paperform makes it easy to manage your review process:

• Organize submissions in your Paperform dashboard with filters, search, and export options
• Route applications automatically using conditional logic based on funding amount requested or medical condition
• Integrate with your workflow tools via Stepper (stepper.io) to trigger review assignments, committee notifications, and approval workflows
• Generate reports with AI Insights to understand application trends, funding needs, and program impact

Connect Paperform to your CRM, donor management system, or project tools to keep application data flowing smoothly through your organization without manual re-entry.

Who This Template Is For

This patient assistance fund application is ideal for:

• Hospital and health system foundations providing financial aid to patients
• Disease-specific charities (cancer funds, kidney disease foundations, rare disease organizations)
• Community health centers and free clinics offering support for uninsured or underinsured patients
• Prescription assistance programs helping patients afford medications
• Medical equipment funds providing wheelchairs, prosthetics, or home care equipment
• Emergency medical expense funds covering urgent or unexpected healthcare costs

Customize for Your Foundation's Unique Requirements

Every patient assistance program has different eligibility criteria, funding caps, and documentation requirements. With Paperform's doc-style editor, you can easily:

• Add or remove fields to match your specific application requirements
• Adjust income thresholds and financial need calculations
• Include program-specific questions about diagnosis, treatment stage, or geographic eligibility
• Customize confirmation messages with your foundation's contact information and review timelines
• Apply your brand with custom colors, fonts, logos, and imagery

No coding required—just edit the form like a document and publish updates instantly.

Secure, Professional, and Trusted by Nonprofits Worldwide

Paperform is SOC 2 Type II compliant and trusted by thousands of nonprofits globally. With data encryption, secure submissions, and flexible data residency options, you can collect sensitive financial and medical information with confidence.

Whether you're processing dozens or hundreds of applications per month, Paperform scales with your foundation's needs while keeping the experience simple for both applicants and your review team.

Get Started Today

Launch your patient assistance fund application in minutes with this ready-to-use template. Customize it to match your foundation's brand and eligibility criteria, then share via your website, email campaigns, or social media to start helping patients in need access the care they deserve.