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Do You Qualify?

Fill in the Form or call us directly at (+1) 661-404-4748

Download and fill out the form located at the bottom of the page, in the language of your preference, carefully following the instructions. Please be sure to send copies; the original documents will not be accepted. If you have any questions, please contact our office Monday through Friday from 9:00 a.m. at 5:30 p.m. and ask to speak with Abby Hannah, executive assistant. Thank you!

(+1) 661 404-4748

[email protected]

3811 Mount Vernon Ave., Bakersfield, CA 93306

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Returning Your Application

Follow These Steps To Return Your Application

Step 1) Download & Print Out The Form
Step 2 ) Fill out The Form
Step 3 ) Scan and upload the complete form
Or you can fax the application to 661.327.7255

First Name
Last Name
Your Email
Please upload your application here.
Make sure you have filled out and scanned your application before proceeding.
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Criteria to qualify:

  • No medical health insurance.
  • Low income. Federal Poverty Level (FPL) per person is $12,140 per year; per couple it’s $16,460. Add $4,320 per additional member in the household.
  • Have a minimum of 10% of the value of your surgery and for every employed adult in the household an additional 5% must be included in surgery cost before applying.
  • To submit your application your monthly and annual income must be verifiable.
  • You will need to have your consultation and surgery in Bakersfield, CA.

Requirements:

  1. Copy of patients Identification.
  2. Must have a medical diagnosis from a family doctor or specialist. If the patient does not have one, we recommend calling CSF Foundation to receive specialized information at (661) 404-4748.
  3. Employment verification for all who work in the household
  4. Last 3 months of check stubs for everyone who works in the household.
  5. Most recent rent receipts
  6. Utility receipt (showing residency address).
  7. Checking and Saving bank account statements for the last 3 months. If you do not have any bank accounts, please write a note stating so. Make sure to write your name, date, and sign the document.
  8. Most recent tax returns for all the tax payers of the household .

RIGHTS & RESPONSIBILITIES

  1. You have rights and responsibilities when you apply for financial assistance for surgical services with CSF Foundation. Your most important right is to be treated equally regardless of race, skin color, national origin, politics, religion, gender, age, disability, sexual orientation, and or immigration status.
  2. You can receive assistance with your application or financial documents.
  3. You will be treated with courtesy, respect, and consideration.
  4. To apply does not guarantee approval for financial assistance.
  5. CSF Foundations committee will determine eligibility and amount of financial assistance provided.
  6. You could qualify for total or partial payment for your surgery according to what the committee approves and advices.
  7. We will only consider applicants with an established surgical diagnostic which will be evaluated by a CSF physician.
  8. If the applicant has been approved for CSF Foundation financial assistance, completion of surgery will depend on the assessment of the specialist-surgeon, and/or in some cases the anesthesiologist.
  9. In case of approval, if the applicant presents serious medical illness, surgery will be considered once those pre- existing conditions are stabilized and suitable for surgery.
  10. All applicants who live outside Bakersfield, CA must be willing to travel to Bakersfield, CA to receive their evaluation and surgical services if applicable.
  11. CSF Medical Non-Profit Foundation has the right to use any medical institution to perform the surgery. All approved amounts will be given directly to the institutions. Applicants under no circumstances receive any amount.
  12. All applicants must participate in an interview either in person or by the phone conducted by a CSF Foundation medical counselor.
  13. All approved applicants have the responsibility to provide written and/or filmed testimonies in the benefit of CSF Foundation in order to execute marketing campaigns or proof to donors and sponsors. All approved funds are available to approved patients for no longer than 3 months from the initial approval date. If for whatever reason the patient does not use the allowed funds within the 3-month period he or she must reapply to CSF Foundation.
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