Lung Transplant Grant Assistance DUE TO HIPAA REGULATIONS, APPLICANT MUST AUTHORIZE SOCIAL WORKER TO CONFIRM THE CF DIAGNOSIS WHEN CONTACTED BY THE BONNELL FOUNDATION. Printable version of this form (PDF). Applicant Info ( * = required field ) Applicant must attach Proof of CF diagnosis letter on CF clinic letter head. This letter must include a direct email, phone number and name of the social worker. (Formats: PDF, DOC, DOCX, JPG, PNG. Limit: 4MB) CF Lung Transplant Candidate Info CF Clinic Info Physician's Info Financial Info Attach Information Needed to Pay Bill/Receipt (Formats: PDF, DOC, DOCX, JPG, PNG. 4MB limit) I agree that if my request is approved and I receive financial assistance - I will write a letter to The Bonnell Foundation about how the funds helped me. This will include providing a photo of myself and creating a video for The Bonnell Foundation fundraiser event. This has no impact on whether or not I will be awarded funds. This is a needed tool to show who The Bonnell Foundation helps, and to encourage others to give to our programs. Please leave this field empty. Lung Transplant Grant Assistance DUE TO HIPAA REGULATIONS, APPLICANT MUST AUTHORIZE SOCIAL WORKER TO CONFIRM THE CF DIAGNOSIS WHEN CONTACTED BY THE BONNELL FOUNDATION. Printable version of this form (PDF). Applicant Info ( * = required field ) Applicant must attach Proof of CF diagnosis letter on CF clinic letter head. This letter must include a direct email, phone number and name of the social worker. (Formats: PDF, DOC, DOCX, JPG, PNG. Limit: 4MB) CF Lung Transplant Candidate Info CF Clinic Info Physician's Info Financial Info Attach Information Needed to Pay Bill/Receipt (Formats: PDF, DOC, DOCX, JPG, PNG. 4MB limit) I agree that if my request is approved and I receive financial assistance - I will write a letter to The Bonnell Foundation about how the funds helped me. This will include providing a photo of myself and creating a video for The Bonnell Foundation fundraiser event. This has no impact on whether or not I will be awarded funds. This is a needed tool to show who The Bonnell Foundation helps, and to encourage others to give to our programs. Please leave this field empty.
