Medical Payment Request Form - LivLyme Grant Kids

LivLyme Grant Recipient Families,

Grant money may be used for treatment by doctors/clinics (MD/DO/LLMD/LLND), medications and supplements. We cannot award grant funds for assistive or adaptive equipment such as in-home HBOT, Rife machines, saunas, biomats, wheelchairs or service dogs. Funds may not be used for medical marijuana.

Grant funds will be paid directly to the provider of goods or services. We can pay for appointments, and we can also make arrangements to pay for online medicine and supplements, if the organization you order from will work with us. This request form MUST be filled out for each appointment, etc. and it MUST be filled out prior to payment. This is your authorization allowing us to pay a provider. We will not pay anyone without your authorization. Please allow two weeks for payments to process.

By completing this form you are hereby granting permission for the LivLyme Foundation to communicate with your provider, pharmacy or supplement company listed below including making payments and discussing the billing for past, current or future services rendered.

Please fill out the form completely.

Patient Information

Grant Recipient(Required)

First Last

Grant Recipient Birthdate(Required)

Grant ID(Required)

Parent Information

Parent Name(Required)

First Last

Parent Phone(Required)

Parent Email(Required)

Patient/Account Number at Provider's Office (if applicable)

Provider Information

Provider Full Name (Doctor, Practitioner etc.)(Required)

Provider Title/Medical Designation(Required)

M.D. (Medical Doctor)

N.D. (Naturopathic Doctor)

Third Choice

D.O. (Doctor of Osteopathy)

N.P. (Nurse Practitioner)

P.A. (Physician Assistant)

Other

Please Specify

Payment Amount Authorized(Required)

Funds will be used to pay for goods or services as follows. Please check all that apply.(Required)

Doctor appointment

Treatment at doctor appointment

Medicine or supplements

Other

Please Specify

Appointment Date OR Pharm/Supplement Company Order Date(date you need funds paid by)(Required)

Please enter the time of the appointment(Required)

Pharmacy / Supplement Company Information

If request is for a prescription from a pharmacy or supplement company please complete:

Pharmacy / Supplement Company Name

Pharmacy / Supplement Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pharmacy / Supplement Company Email (if applicable)

Pharmacy / Supplement Company Billing Phone

Provider / Supplement Company Billing Information

Please Select One:

Care Provider (Doctor)

Pharmacy

Supplement Company

Billing Contact Name

First Last

Company/Business Name

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Phone

Billing Email

Provider / Supplement Company Website(Required)

Is there any additional information you would like to share? Do you have any questions?

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