Encompass Cares Employee Emergency Relief Fund Online Application

NOTE: Incomplete requests will not be processed. Supporting documentation is required and must be submitted with the application. Examples of documentation include eviction/foreclosure notices, past due utilities, police/fire report, invoice of funeral expenses, statements from health care providers or explanations of benefits from insurance indicating applicant’s out-of-pocket medical expenses; the documentation must substantiate the amount of financial assistance being requested. Documentation must be on letterhead or statement of owned party. Email supporting documentation to Emergency@encompasscares.org

Name of Applicant:*
Name of Form Submitter (if not applicant):
Relationship to Applicant (if not applicant):
Home Address:*
Personal Phone*
Work Phone*
E-mail Address*
Employee ID:
Applicant's Office Location:*
Work Address (enter the address of the applicant's Encompass branch office):*
Applicant's Occupation/Title:*

Emergency Type (must select at least one)

Please select hardship type:
Select dependent type:
Select non-dependent family type:

Eligibility - must attest to all three

Level of Need and Distress

Please provide a narrative for the following:

Extent of damage or suffering:*
Income prior to emergency:
Number and age(s) of dependents:
Other sources of aid:*
Amount requested:*

Certification of Documentation

Check one of the following:

* I hereby certify that I have sent, or will today send, supporting documentation attached in an email to Emergency@encompasscares.org, or in the mail to Encompass Cares
* I do not have access to supporting documentation. The supporting documentation is not in my possession due to the damage sustained as a result of the emergency. I agree to make my best reasonable efforts to obtain copies of such missing documentation from other sources and submit such copies to Encompass Cares if and when obtained

Mailing address:

Encompass Cares
Attn: Emergency Relief Fund
6688 N Central Expy. Ste 1300
Dallas, TX  75206

**Encompass Cares shall not obtain any information that would constitute "protected health information," as such term is defined in 45 CFR 160.103, from Encompass Health, Homecare Homebase, or their wholly owned subsidiary or affiliate or any group health plan sponsored by one of the aforementioned parties.

Enter the characters in the box: