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This section must be completed by a social worker, nurse, or doctor. All information will be verified by patient. We do this as a requirement of our 501c3 non profit status.

Eligibility for our Extended Hospital Stay Fund Program is as follows:

  • Any child or adult diagnosed with cystic fibrosis who has experienced a 14 consecutive day hospital stay within the last calendar year.

  •  In order to review the request for financial assistance, a hospital professional (Doctor, Nurse or Social Worker) must complete and submit this referral form.

* Financial assistance is typically a one-time payment for approved applicants paid to a third party vendor on applicant’s behalf. 

We use Submittable to accept and review our submissions.