Free Health Grant & Service Request
Please complete this form to retrieve your no-cost health related services performed by Key Better Days Society. You'll be contacted once your health grant has been approved!
  • Medicaid Carriers-Please Apply!
  • Please allow up to 4 weeks before contacting Key Better Days Society regarding your submission.
  • If you have a life threatening illness or emergency, please do not fill out this form!-Please call 911 or schedule an appointment with your primary care provider.
 Questions? Please Email Betterhealth@keybetter.org or call us at 513-613-7111 Monday-Friday 11 am-3 pm.
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Name (First & Last) *
Client's Name (First & Last)-If same as above-SKIP!
Date of Birth *
MM
/
DD
/
YYYY
Email *
Why do you or the client need personal care services?
Home Address- Homeless?; Address Where Services Render  *
Address ( Requested Service) if same as home, please skip.
I am; *
Please check all that apply; *
What hours and days of the week work best for you? *
DISCLAIMER
Key Better Days Society is a 501c3 organization that conducts health services and procedures to disadvantaged indivduals. This form is used for informational purposes only and fully HIPPA compliant;we disclaim liability of any kind whatsoever, including; diagnosis, without limitation, liability for quality, performance, merchantability and fitness for a particular purpose arising out of the use, or inability to use this data. If you're experiencing life threatening symptoms please call 911.  
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