Enhabit 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 Enhabit 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 Enhabit 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 Enhabit Cares if and when obtained

Mailing address:

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

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

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