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Qualifications

Our Mission to help those in need…

TCT Health Foundation would like to help as many people as possible. Given the high volume of people that need home care, there is select criteria that someone needs to meet in order to qualify to receive benefits from TCT Health Foundation. The criteria is generally built around net worth and income requirements, as well as not having access to other resources that help provide home care benefits. Below is a list of our requirements to qualify.

General Criteria:

Must be 18 years of age or older; must be considered an adult.
Does not qualify for any insurance for Home Care or Home Health.
Does not have any long-term care insurance.
Not receiving funds from other agencies, non-profits, special groups, or religious affiliates for the same time of care.
Not a US Veteran nor belong to any affiliated groups such as tribunal. (Affiliated groups have their own home health funding, however, there are exceptions to this rule).
Must be a US Citizen.
Must be a California resident and live within Orange, San Diego, Los Angeles, and Riverside Counties.
Annual income of $50,000 or less.
Total net assets of $100,000 or less.
Must be willing to submit financials and a list of assets for proof of financial hardship.
Person(s) on Medi-Cal may qualify depending on certain criteria.
Must have a critical need for Home Care or Home Health such as long-term illness, disability, limitations on mobility, mental illness, recovering from major injury or surgery.
Must reside in a residential living space or an approved living facility.
Must not be in a hospital or skilled nursing facility.
Length of service will depend on the Person(s) needs, qualifications, and funding.

Application

Patient Information

Name

First

Last

Today's Date

Phone

Phone (Alternative #)

Address

City

State/Province

Zip/Postal

Date of Birth

Social Security #

Medicare Insurance?

Yes

If yes, please provide Medicare ID #:

Med-Cal Insurance?

Yes

If yes, please provide Medi-Cal ID #:

Please List other Insurance Policies that you have. Include the Insurance Company and Policy # listed on your beneficiary ID card.

List any Known Allergies:

Medications:

Primary Physician:

Physician Phone:

Any Secondary Physician with Phone Number:

Reason for Need of Home Care or Home Health:

Requested Frequency (Include specific days and times)

Additional Notes & Comments:

Paragraph

Print Patient's Name:

Patient's Signature

Clear

Date

Patient Representative's Information