FORM SECTION What are you requesting MKF to help with?
What are you requesting Minnesota Kids Foundation to help with? *You do not need to provide medical records, detailed diagnoses, or financial documents at this stage.
FORM SECTION Insurance & provider information
Do you currently have insurance? *Select Yes No
What type of insurance do you have? *Select Private / employer-provided insurance Government-provided insurance Other / unsure
Have you already met with the provider? *Select Yes No
What treatment or service has the provider suggested? *
How often is the treatment or service expected? *
How long is the treatment or service expected to continue? *
FORM SECTION Timing
How soon is assistance needed? *Select Immediately / urgent Within 2 weeks Within 30 days More than 30 days Unsure
FORM SECTION Anything else we should know?
Is there any additional information that would help us understand your request?
FORM SECTION If MKF continues reviewing your request
If requested, would you be willing to provide basic financial information so MKF can better understand the need? *Select Yes No You are not being asked to provide financial information today. This only tells us whether you would be willing to provide basic information later if requested.
If requested, would you be willing to provide the provider's name and contact information? *Select Yes No
If requested, would you be willing to sign a limited release allowing MKF to communicate with the provider only for purposes related to scheduling, cost, and payment? *Select Yes No This is not a blanket release of medical records. If a release is later needed, it would be limited to information necessary for MKF's review, scheduling, cost, and payment coordination.
