Encompass Cares Employee Emergency Relief Fund Online Application

NOTE: Incomplete requests will not be processed. Supporting documentation and signatures are required and must be submitted with the application (examples of documentation include eviction/foreclosure notifications, past due utilities, policy/fire report, invoice of funeral expenses, doctor's note and other related documentation.) Documentation must be on letterhead or statement of owned party. Email supporting documentation to kpedigo@encompasscares.org

Name of Applicant:*

First

Last

Name of Form Submitter (if not applicant):

First

Last

Relationship to Applicant (if not applicant):

Home Address:*

Street AddressCityStateZip Code

Personal Phone*

Area Code

Phone Number

Work Phone*

Area Code

Phone Number

E-mail Address*

Employee ID:

Applicant's Employer:*

Work Address (enter the address of the applicant's Encompass branch office):*

Street AddressCityStateZip Code

Applicant's Occupation/Title:*

Emergency Type (must select at least one)

Physical or natural disaster resulting in the significant loss to home or personal property

Victim of a crime

Personal hardship

Please select hardship type:

Select dependent type:

Resides in employee's home at least 50% of the time

Treated as a dependent for tax purposes; OR

Employee provides at least 50% support

Select non-dependent family type:

Adult child

Parent or grandparent

Sibling for whom there are no other family members

Eligibility - must attest to all three

I am a current employee with at least 90 days service

I attest that I have not received financial assistance from Encompass or HCHB Cares in the past 12 months

I attest that I am not a Director or Officer of Encompass Health or HCHB

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 kpedigo@encompasscares.org, or in the mail to Encompass Cares

True

* 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

True

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.