Funded by AdventHealth Palm Coast Foundation Impact Fund and Flagler Cares

This Barrier Removal Fund will be available to Flagler Cares' partners to remove barriers that individuals and families experience when seeking access to critical health and social care services.

*Any organization submitting a request on behalf of a client must have a signed Release of Information on file for that client prior to submitting this form.

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* Contact Information for Requesting Organization (must be a current Flagler Cares partner)

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* Describe the Barrier to Health/Stability that your client is experiencing and how this one time funding will remove the barrier and create access to care.

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* Amount of Funds Requested (one time funding to remove a barrier to health and stability)

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* Please answer Yes to this question to confirm that you have verified the amount owed by your client to the vendor being paid, and you have reflected the verified amount in question 3.

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* Payment Details
(payments must be made to a company/vendor or the requesting organization--no payments will be made directly to a client)

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* Company W9 (required for direct payment)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* Client Information

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* Is this payment time sensitive?
If yes, please be sure that you are submitting this form at least 3 business days before the payment due date.

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* If your request for payment through this fund is approved, you will be required to complete a short impact statement detailing how this assistance removed barriers to health/stability. By answering "Yes" to this question, you are agreeing to fulfill this requirement on behalf of your client.
On the next page, there will be a link to download the Impact Form to complete. You can also download the Impact Form from www.flaglercares.com/barrier.

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