The Houston Area Continuity of Care has established a particular fund that is designed to help those
people who are experiencing a financial hardship due to a medical crisis. This fund is known as the
Discretionary Fund.
Discretionary Fund applications must be made through a current Houston Area Continuity of Care
member. The distribution of funds is limited to $200 per person, per year and in the past has paid
for overdue utility bills and desperately needed medication. All checks are made out to the billing
organization and not to an individual.
Please complete the following information:
MEMBER’S INFORMATION
H.A.C.O.C member’s name
Member’s telephone number
Company Name
APPLICANT’S INFORMATION
Applicants name
Applicants Telephone number
Applicants address
BILLING PARTIES INFORMATION
Name of Organization
Organization’s Address
Account Number
Amount
Due date of account
Customer Service Tel #
SUMMARY OF SITUATION
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The decision to distribute funds is at the sole discretion of the board of the Houston Area Continuity of Care.
Discretionary Fund Request Form
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