Patient Application

If you believe that you or someone you know needs financial assistance to receive cardiac care, please read this information and submit your request using the form below.

Who We Help
What Is Covered
Where We Help
Application Form

WHO WE HELP

Eligible patients must meet the following minimum criteria:

US citizens or have a legal right to be in the US (proof of passport, visa, green card, etc. required)
Do not have financial resources to pay for the procedures themselves
Do not have any insurance
Do not qualify for any state or federal support (i.e., Medicare, Medicaid)
Be free of any criminal conviction

WHAT IS COVERED

NOTE: Funds are sent directly to the hospital for reimbursement, not to the individual.

We pay for cardiac-related procedures that are:

Performed and approved by us in advance
Performed in one of our affiliate care centers with one of our doctors

At the current time, we do not provide funding for:

Procedures at hospitals that are not in our network, or have not been approved by us
Procedures that are not cardiac-related, initial diagnostic tests
Heart transplants
Prior surgeries or previous medical expenses
Insurance co-payments
Travel or hotel expenses

WHERE WE HELP

Our partner care centers are located in:

Los Angeles, CA
Washington, DC
New York City
Atlanta, GA
Cleveland, OH
Tampa Bay, FL
Houston, TX
Miami, FL
Chicago, IL

APPLICATION FORM

Once this information is received the foundation will promptly consider the request. Decisions on requests are made within 30 days.

If you have any questions about funding please complete the form below. All applicants are cautioned to rely on the advice of their own health care providers and not to delay seeking treatment while awaiting a funding determination from the Foundation.

1. Please provide your contact information.

*

First Name: Required

*

Last Name: Required

*

Email: Required

City:

State / Province:

Country:

*

Phone Number: Required

Yes, I would like to receive e-mail from Larry King Cardiac Foundation

Yes, I would like to receive postal mail from Larry King Cardiac Foundation

Remember me. What's this?

2. Question - Not Required - If you are not the patient in need, please enter the patient's full name:

3.

Question - Not Required - If you are not the patient in need, what is your relationship to the patient: Parent
Spouse
Relative
Friend
Co-worker
Other

*4. Question - Required - Please describe the patient's condition or cardiac care needs:

*5. Question - Required - What is the name of the patient's Primary Physician?

*6. Question - Required - What is the name of the patient's hospital?

*7. Question - Required - Hospital location - City:

*8. Question - Required - Hospital location - State:

9.

Question - Not Required - Is the patient in question a: US citizen or have a legal right to be in the US with proof of passport, visa, green card, etc.
Currently living outside the United States
Unknown

*10.

Question - Required - Is the patient qualified for Medicare, Medicaid or have insurance? Yes
No
Not sure

PLEASE NOTE: If the initial request falls within our guidelines, applicants interested in receiving funding from the Larry King Cardiac Foundation will be asked to provide the following information:
- A biographical letter regarding the applicant to provide the committee an opportunity to understand the background of the individual seeking assistance
- A letter from the applicant's primary physician, setting forth his/her present condition and prognosis. In the letter, the planned operative course of treatment should be set forth
- A statement of financial condition as to the applicant, including all assets and liabilities
- A copy of any and all health insurance documentation regarding 3rd-party benefits

The Larry King Cardiac Foundation recognizes the following sponsors:

Copyright 2009 Larry King Cardiac Foundation | Contact Us | Privacy Policy | Login
Larry King Cardiac Foundation : 15720 Crabbs Branch Way Suite D Rockville, MD 20855 : 866-302-LKCF (5523)