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?


Have you applied before?


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?


   
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


Health Insurance


     
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