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Request For Services Form

Please Fill Out And We Will Contact You and Your Service Providers

WE CARE HEALTHCARE INITIATIVE
FILL OUT COMPLETELY AS BEST YOU CAN

Email *

Firstname

Lastname

Enter what you are requesting services for and who is providing these services *

I AGREE That all Questions Were Answered Honestly or I Maybe Charged with Fraud If Any Money I receive was Fraudulent . *

Address

City

State

Postalcode

Phone *

Country

  • Make Sure all this information at a minimum is included. 

    • Your Full Name as is on your Countries Legal ID or Passport

  • A Front and Back picture of a Legal License or State or country ID or Passport

  • The Name of any receiving facility, person, business


    The Phone number


    The reason in a short explanation of one or two paragraphs 

  • The Name Of Emergent issue


     Dr's Name and Phone number


    Name of Hospital or Facility


     it's Phone Number include your Social Workers Name We Can Clarify any Questions with. 

  • Financial Statement to include no employment, unemployment, A recent paystub, (Annual Net Salary and Monthly Expenses For Large Money Requests over $2000.00)

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