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Applicant Guidelines:
General:
The program was established to ensure veterinary care for pets owned by qualifying individuals. The fund to support this program is dependent upon the generosity of pet lovers. The Animal Health Foundation, the sponsor of the program, will select qualified individuals who meet the stipulations stated herein and will award benefits as follows:
1. Pet health insurance to cover emergencies, illness diagnosis and treatments, which meet the guidelines of the insurance policies and riders.
2. Benefits will be paid directly to the treating hospital.
3. Some veterinarians may elect to reduce or waive co-payments; however, recipients will be responsible for co-payments as specified in the insurance policies.
Applicant Requirements:
1. Applicants must be 65 years old or permanently disabled, and must demonstrate financial need for assistance in providing veterinary care for pets. Applicant must live in Manhattan Beach/South Bay, CA area.
2. A.H.F. may request verification of applicant's financial need, as demonstrated on most recent Federal/State income tax returns.
3. Benefits may be awarded to a maximum of 2 pets per recipient, and proof of ownership may be requested.
4. Awards are made for family pets only, not for stray animals.
5. Pets must have been in the household for a period of 90 days prior to application.
Applicant Information:
(please fill in form and then print form and mail or fax to the Animal Health Foundation.)
or faxing)
Person to contact in case of emergency:
Do you have a disability? If yes, please explain:
Who referred you to this program?
Approximate Monthly Income/Sources:
Fixed Monthly Financial Obligations:
PET INFORMATION:
Species: cat dog bird other:
Does your pet see a veterinarian regularly?
yes no
Does your pet currently have any known health problems? Describe.
Is your pet currently receiving assistance from any other group or individual?
Who is assisting you and how may we contact them?
How much are they providing?
How did you hear about this program?
What does your pet mean to you?
I have read and understand the Animal Heath Foundation's Guidelines Assistance Program, and I state that the above information is true and factual
.Signature: ______________________________________
Date: _
_/_ _/_ _
Please Send:
via FAX to 323-954-0507 OR
mail to: A.H.F. 12021 Wilshire Boulevard Suite 264 Los Angeles, CA 90025.
Email comments to: JLaureen@animalhealthfoundation.net.
Office use only:
Review by/date:
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