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Application Forms: Instructions

“Family, Friends & Community coming together as ONE Serving the Entire Smithtown Community”

APPLICATION INSTRUCTIONS:
The Smithtown Children’s Foundation, is a NY State not for profit, 501c3 providing financial and emotional support to
families residing within the Smithtown School District. This Foundation is independent of the Smithtown Schools
District or any other organization having similar objectives.

1) Applications will only be accepted for families whose primary residence is within the Town of Smithtown. Proof of residency may be required.

2) Families may be nominated by a third party for assistance. We (SCF) will in turn contact the nominated family. They must provide the foundation with their own application, physician form, photo and other release forms.

3) In cases of guardianship, proper documentation must be submitted to the Foundation.

4) Please be specific regarding what type of assistance the family needs and utilize the correct application.

5) Questions may be directed to the Foundation office by calling during normal business hours or by email to any of the email address listed below:
Christine Fitzgerald- fitzyBBCF@optonline.net
Kristy Jaeger- Krbenefit1015@aol.com

6) The Medical Hardship Application & Physician's Information Forms MUST be completed and returned to the Foundation's office listed on this form if requesting our help due to medical reasons/illness.

7) The Financial Hardship Application & your most recent tax return MUST be completed & returned to the Foundation’s office to be considered for assistance.

8) The Release and Indemnification Form MUST be signed, notarized & mailed with the both the completed medical & the financial applications.

9) HIPAA NOTICE: - The United States Congress recently enacted the Health Insurance Portability and Accountability Act (HIPAA), which took effect on April 14, 2003. HIPAA was designed to protect patient medical records and other health information provided to health plans, doctors, hospitals and other health care providers. In order to comply with this federal law, The Smithtown Children’s Foundation, now requires that the parent/legal guardian sign and return the HIPAA Form in order to process the application. The physician’s application requires a response from the applicant’s treating physician. The physician should require the applicant’s parents/legal guardian to complete and sign a HIPAA form during the treatment process. Please ensure, before returning the physician’s portion of your application, that a signed copy of the HIPAA form accompanies this document. If a HIPAA form has not yet been completed, please call the treatment facility and request one.

Please note: the wish application cannot be processed without the signed HIPAA form.

Smithtown Children’s Foundation
PO BOX 799, Nesconset, NY 11767
Christine Fitzgerald
516-835-1219 l fitzyBBCF@optonline.net
Kristy Jaeger
631-258-0545 l Krbenefit1015@aol.com

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