Program Information

Please complete all the information on this form so we can enter your program into our database.

Program Name
Sponsoring Organization
Address Line
Address Line
City, State and ZIP
Local Phone
Toll Free Phone
Fax
E-mail
Website
Hours/Days of Service
Who You Help (Be specific)
How You Help (Be specific)
Geographic Area Serviced
Services You Provide
Eligibility Criteria
How to Apply
Is your organization non-profit?	Non-ProfitFor-Profit
Do you charge a fee?	YesNo If yes, how much?
Languages
This following information is for our files only and will not appear on the website.
Please check one or more of these descriptions to help us categorize your program:
	This program or foundation is based on a specific disease, assists patients with health-related expenses (including financial grants, insurance copays, the purchase of some health-related goods or other assistance with expenses).
	This program helps patients find and apply for Patient Assistance Programs and other types of assistance.
	This program is funded and administered by the state.
	This is a Free Clinic that provides direct medical, dental or mental health services at little or no charge or on a predefined sliding scale.
Contact Person
Contact's Phone
Contact's Email
Contact's Address (if different from above)
Other Comments