Application for “My Wishes”
Please Note: If you are completing this application on behalf of a hospice patient other than yourself, please fill out
each section in accordance to the hospice patient’s information.
Section A: Contact Information
Patient’s Name:
Mailing Address:
Phone #:
First
Street
City
Application Completed By (of other than patient):
Middle
Email:
Last
State
Zip Code
Relationship to Patient:
Hospice/Palliative Care Provider:
Contact Name:
Section B: Wish Detail
Phone #:
Contact Phone #:
Please be specific in your answers and include as much detail as possible.
Describe the Wish:
History behind the Wish:
Will others be involved in this Wish? If so, who?
What has prevented you from fulfilling this Wish on your own?
Section C: Patient’s Personal History
Before we move forward with a wish, we would like to try and get to know you. Please take the time to tell us a little
about yourself.
What are some of your interests, hobbies and/or passions?
Are you/is the patient a legal resident or citizen of the United States?
Are you/is the patient within the last three (3) months of life?
Yes
Yes
No
No
Are you/is the patient within the last six (6) months of life?
Yes
No
Do you/does the patient have any physical or cognitive impairment
that may influence your/their ability to participate in the Wish?
If yes, please provide details:
Yes
No
Have you/has the patient even been convicted of a crime?
If yes, please explain:
Yes
No
Section D: Funding Request
NB: My Wishes assistance is limited to $250.00/application. Submission of application does not guarantee award of
total requested amount.
Expense
Amount Requested
Section E: Medical Verification and Photo & Liability Release
Please sign and submit the Photo and Liability Release Form along with your application. Receipt of the signed
liability section is required for Wish fulfillment. Photo release section is optional, but encouraged. Photo may be
used on HCF social media tags for, for promotion of the "My Wishes" program and/or on the HCF website.
If your wish involves any extreme physical activity or travel of any kind, please have your doctor sign the Medical
Verification section of the Liability & Photo Release Form.
Form Enclosed
Certification
By signing below, I acknowledge that acceptance of this application by Hospice Care Foundation (HCF) does not
constitute a commitment by HCF to fulfill the Wish request. If HCF determines this Wish should enter the next
stage of evaluation, an HCF representative may contact the applicant and/or their hospice/palliative care
provider for more information. I also understand that this contact does not constitute a commitment to fund the
Wish. Furthermore, I certify that I meet/the patient meets all qualifications for eligibility, and declare that all of
the information given by me in this application is true to the best of my knowledge, and I agree to inform HCF in
a timely manner should any information provided in this application change.
Signature:
Date:
Printed Name:
Relationship to Patient:
Title (if hospice provider):
Please return completed form to:
Hospice Care Foundation
715 Kensington Ave, Suite 2C
Missoula, MT 59801
Questions may be directed to Kevi Berger at
406-541-2255 or [email protected].
HCF Admin Use Only
Received By:
Date:
Application Complete:
YES
Title:
Wish Approved:
Funds Awarded:
Amount: $
YES
YES
Rev. 062016/TKW
NO
NO
NO