Mending Kids · Hometown Mission Application Form

Information & Eligibility Guidelines

Mending Kids is a 501(c)(3) surgical nonprofit organization which provides free surgical care for underserved children around the world. For over 13 years we have mended children in over 66 countries. In 2013, we launched our first US-based surgical mission. Serving children in Southern California, our Hometown Mission program provides a chance at a better life for kids whose conditions have been deemed “non-life-threatening” or “elective” by insurance providers. We know that for a young boy with a large hairy nevus on his face, or a little girl in need of cleft-nose reconstruction, who may feel self-conscious or experience bullying as a result of their physical appearance, surgery can be truly life changing.

Please read the guidelines below to determine whether a child you know may be eligible for this program!

Which Conditions are Covered?

For the Hometown Mission, we only accept patients requiring elective outpatient, same-day surgeries. We do not accept patients that needing emergency inpatient care, organ transplants, or who have cancer or chronic conditions requiring multiple surgeries.

Covered conditions/procedures include:

Lip Palate
General surgeries
Facial Clefts
ENT procedures
Facial Tumors, Hemangiomas
Urology procedures
Plastic, Hairy Nevus
Orthopedic, burns reconstruction

Who is Eligible?

Children and young adults aged 0-21 years old
Live in Southern California or be willing to arrange transportation to Southern California
Deductible/procedure cost is greater than 10% of total household income
Have been denied coverage by insurance provider or cannot afford cost of surgical care
Note: No proof of legal status is required to receive care through Mending Kids

Referral Information

Please fill out if you are not the parent to the child.

Name

First Name

Last Name

Email

Verify Email

Phone Number

Relationship to Child

How did you hear about Mending Kids?

Patient Information

Name

First Name

Last Name

Sex

Male

Female

Date of Birth

(mm/dd/yyyy)

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Ethnicity

Hispanic/Latino

Black/African-American

White/Caucasian

Asian

Other

Ethnicity

Primary Language

Need Interpreter?

Yes

No

Parent/Guardian Information

Guardian's Name (if applicable)

First Name

Last Name

Father's Name

First Name

Last Name

Father's Phone

Father's Email

Verify Email

Father's Occupation

Mother's Name

First Name

Last Name

Mother's Phone

Mother's Email

Verify Email

Mother's Occupation

Primary Language

Need Interpreter?

Yes

No

Patient Medical Information

What surgery does the child need?

Child's Diagnosis

Was the Diagnosis confirmed by a physician?

Yes

No

What type of physician?

Primary care doctor, surgeon, etc.

Name of Child's Primary Care Physician

Prefix

First Name

Last Name

Suffix

Physician's Phone Number

Physician's Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Any other past/present medical problems?

Current Medications

Allergies

Insurance & Income Information

How many people live in the child's household?

What is the total annual household income?

What type of insurance does the child currently have?

Medicaid - Full Scope

Medicaid - Emergency

Medicare

Private Insurance

No Insurance

Other

What type of insurance does the child currently have?

Have you applied for surgery through your insurance provider?

Yes

No

If yes, what was the outcome?

Do you have a denial letter from the insurance company?

Yes

No

Please attach the denial letter from the insurance company

What is your primary reason for seeking care through Mending Kids?

Child has insurance, but the surgery was denied by the insurance company.

I have insurance but cannot afford to pay the high cost/deductible.

I do not have insurance and cannot afford to pay for surgery out of pocket.

Other

Cost of the deductible

Cost of the Surgery

Other

I hereby certify that the information contained in this form is true and correct to the best of my knowledge and belief. I understand that submitting this form does not guarantee the provision of services.

Los Angeles - Hometown Mission

Hometown Mission Application Form

Referral Information

Patient Information

Parent/Guardian Information

Patient Medical Information

Insurance & Income Information