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Senior Charity Care Facility Request
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Today's Date
*
MM
/
DD
/
YYYY
Name of Facility or Senior Apartment
*
Your answer
Service Being Requested
*
Dental Clinic
Vision Clinic
Required
Address of Facility
*
Your answer
Name of Facility Contact (Resident Advocate, Social Worker, or Other)
*
Your answer
Email of Facility Contact
*
Your answer
Phone number of Facility Contact
*
Your answer
Number of Residents in Facility
*
Your answer
Number of Seniors That Could Attend A Clinic
*
Your answer
Number of Medicaid Patients Requesting to be Seen (Dental Only)
Your answer
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