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Sonia Plotnick Health Fund Application

You may submit your application online or print an application form below to send by mail. For all applications, a copy of all bills should be mailed to SPHF, PO Box 530606, St. Petersburg, FL 33747

To receive monetary help from the Sonia Plotnick Health Fund (SPHF), you must be a permanent
resident of Pinellas, Hillsborough, Manatee, or Sarasota County, and you must be a womyn.

Do you meet this criteria ?   Yes, I do   No, I don't

If you do not meet the above criteria, and want the SPHF Board to consider making 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 administrator 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.

You may submit your application by mail, e-mail or online. A copy of all bills and healthcare provider information should be attached. * No specific payment amount is guaranteed by your application. Payment of funds is dependent upon availability and approval of the SPHF Board.

PRINTABLE APPLICATIONS:   PDF DOCUMENT

You may print one of the forms above and submit by mail with your attachments to:
SPHF, P.O. Box 530606, St. Petersburg, FL 33747

You may email completed form and scanned attachments to:
soniaplotnick@yahoo.com

You may submit the e-mail form below and send your attachments by one of the above methods.

APPLICANT INFORMATION

First Name/M.I.:*
Last Name:*
Address:*
City:*
State:*
Zip:*
Home Phone:*
Work Phone:
Email: *
When is the best time to reach you?
How did you hear about us?

Do you consent for a board member
to contact your provider ?  



Do you have health insurance ?



If yes, health insurance deductible amount:
Co-pay amount:
Prescription Co-pay:
If related to a car accident, car insurance deductible amount:
Short Description of your request:



AFTER SUBMITTING THIS FORM,
PLEASE SEND A COPY OF ALL BILLS TO EXPEDITE THE GRANT PROCESS

MAIL APPLICATION FORM AND/OR BILLS TO:

Sonia Plotnik Health Fund

PO Box 530606, St. Petersburg, FL 33747

Help or Questions, call 727-482-0216