SPHF online application for assistance with women's health care

Application for Financial Assistance

To receive financial assistance from the Sonia Plotnick Health Fund (SPHF), You must be a permanent female resident of Pinellas, Hillsborough, Manatee Pasco, or Sarasota Counties and not have the financial resources to meet your healthcare needs.

Do you meet this criteria?	Yes No	Have you applied before?	Yes No
If yes, when?

If you do not meet criteria and want the board to consider you as an exception, please submit this form along with any explanatory information.

The Board meets monthly and your application will be anonymous to all board members except the administer and will be handled confidentially. Upon approval, we will disburse funds directly to your healthcare provider. We will need your consent to contact your provider. Alternatives to traditional medicine, such as chiropractic, homeopathy, and acupuncture are considered valid requests. Health insurance does not eliminate you from receiving funds.

Applicant Information

Name F/M/L		Address


Telephone(s) W/H/C


Email		Do you want to receive email from us? Yes No

Best Time to Reach You:		Last four digits of Social Security #

How did you hear about us?		Date of Birth

Financial Information
Please provide a copy of all Bills and Provider Information. No amount is guaranteed by application, funds are dependant on availability and approval. Short Description of Request and Amount Requested:*


Consent to contact your provider	Yes No	Health Insurance	Yes No

If yes for insurance:	Co pay amt:	Deductible amt:	Prescription co pay:
Car accident? Deductible amt:

Submit form and send bills via mail or email.

Mail to:		Email to: soniaplotnick@yahoo.com
SPHF P.O. Box 530606 St Petersburg, FL 33747		Scan bills and attach to your email.

Questions? Contact us @ 727-482-0216