Grant Application

Thank you for reaching out! We know the cleft and craniofacial journey is long and we are here to help. Because of generous donors, Smile Oregon can provide grant support to children who qualify. Please read the following criteria before proceeding:

Grant Application - Criteria:
In evaluating applications, Smile Oregon will consider applications based on the following criteria:

The individual receiving care must be 21 years old or younger.
Smile Oregon gives priority to patients living in Oregon.
The patient must be able to demonstrate a clinical and financial need.
In order to be a sustainable organization every patient applicant will be asked to contribute resources based on their financial situation.

If you meet these criteria, we invite you to apply for a grant. Before starting the form, be sure to send the following two forms to your provider and have them returned to you before starting this application. (add link to Patient's Health Care Provider & Craniofacial Provider Forms) You will need the following documents to complete this application:

Current IRS form 1040EZ, 1040A, or 1040 (Please, include all responsible parties.)

Patient's Health Care Provider Form - View and Download Here

Patient's Craniofacial Team Form - View and Download Here

HIPPA Form - View and Download Here

Patient Photo

We encourage you to collect these items prior to starting this application. You cannot submit your application until all parts of the form are complete. Once your application is submitted, you will receive a confirmation email. Typically, grants are approved within 30 days. For questions, please email us at info@smileoregon.org.

Thank You!

Patient Information

Patient's name *

First Name

Last Name

Patient's birth date: *

(mm/dd/yyyy)

Is the patient a (please select one): *

Male

Female

Parent/Legal Guardian name: *

First Name

Last Name

Relationship (please select one): *

Mother

Father

Legal Guardian

Self

Other

If other, please describe

Parent/Legal Guardian name: *

First Name

Last Name

Relationship (please select one): *

Mother

Father

Legal Guardian

Self

Other

If other, please describe

Primary contact phone number: *

Secondary contact phone number: *

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Email *

Verify Email *

Is this the first time you have submitted an application for a Smile Oregon grant? *

Yes

If no, please explain

Name of patient's health benefit plan (health insurance provider, etc...) *

Name of person who carried this health benefit plan: *

What is the relationship of the person who carries the health benefit plan for the patient? *

Does the patient have a second health benefit plan? *

Yes

Name of the patient's second health benefit plan (health insurance provider, etc...)

Name of person who carries this health benefit plan:

What is the relationship of the person who carries the health benefit plan for the patient?

Enter a brief description of the medical history of the patient *

This section is for the patient to complete, NOT THE PROVIDER

Please describe what the Smile Oregon grant will be used for: *

Please give all relevant details (i.e. cost(s), timelines, dates, etc.)

Does the patient's health benefit plan cover some of the cost? *

Please explain

Does the patient's secondary health benefit plan provide financial assistance for this item?

Please explain

Does the patient receive any assistance for this medical item from the public school or private school where he/she attends? *

Yes

If yes, please explain.

i.e. the school provides speech therapy

Has the patient sought assistance to help with the medical item(s)/service(s) you are requesting from other public or private sources? For example, city, county, state organizations and /or other charities?

Please explain

Would your out of pocket costs, after insurance, be best categorized as one-time only cost or recurring cost? *

Please select one

One-time only

Recurring cost

Both

Based on your choice above (one-time or recurring cost), what is your estimated out of pocket cost, after insurance, in whole dollars? If recurring please put the recurring payment amount, not the total amount and the number of payments. *

How did you hear about Smile Oregon? *

Financial Statement

Number of people living in household *

Cash assets (checking, savings, safe deposit box, mattress): *

Investments (401(), IRA's, other): *

Monthly Gross Pay *

Monthly Child Support Income

Monthly SSI, TANF, Food Stamps, etc.

Monthly Other

Additional financial comments (if any):

Add photocopies of the most current IRS form 1040EZ, 1040A, or 1040 (Please, include all responsible parties.) *

Patient's Health Care Provider Form *

https://9bfe3a92-fcc8-4c60-946a-8c1c6ab6cb97.usrfiles.com/ugd/9bfe3a_8601e61ab97149b486c6923b22eed4cd.pdf

Patient's Craniofacial Team Form *

https://9bfe3a92-fcc8-4c60-946a-8c1c6ab6cb97.usrfiles.com/ugd/9bfe3a_ee3fde4d935c4f86b090cc303eec2739.pdf

HIPPA Form *

https://9bfe3a92-fcc8-4c60-946a-8c1c6ab6cb97.usrfiles.com/ugd/9bfe3a_704a92195a11453d8aa5e6c7e825d3c6.pdf

Patient Photo