Case Management Services

MEDICAL SERVICES APPLICATION, ACKNOWLEDGMENT AND APPRECIATION LETTER

The St. Rafka Mission of Hope and Mercy is a religious charity organization in the United States that seeks to provide displaced people in Lebanon with emergency aid to meet basic human needs, including medical care.

Date of Service

A- Personal Information

Patient Full Name

MaleFemale

Patient Date of Birth

Patient Country of Birth

Select Country

Current Country of Residence

Select Country

Select State

Phone

Email *

Patient Religion

Rite

Patient Current Parish

Country

Select Country

State

Select State

Address

Phone

Email

Website

Diocese

Name of the Bishop

Rite of the Parish

Rite of the Parish

Name of the Pastor

Contact Information of the Pastor

Office

Pastor Mobile

Pastor Email

Name of the Priest Assigned by the Local Patriarch of the Local Church to take care of the Refugees Needs of the Specific Church/ Rite/ Country of Origin

Patient Occupation

Patient Education Status

Patient Short Medical Diagnosis And Treatment Received

Doctor's Evaluation and Hospital Discharge form

B- PARENTS’ INFORMATION (In Case Deceased)

Father’s First and Last Name

Victim of War/ Persecution

Natural Death

Victim of War/ Persecution

Natural Death

Date and Place of Death

Mother Full Name

Victim of War/Persecution

Natural Death

Date and Place of Death

C- PARENTS INFORMATION (If Living)

Father’s First and Last Name

Father Date of Birth

Country of Birth

Select Country

Place of Birth

Select State

Father's Religion

Rite

Mother's First Name

Maiden Name

Date of Birth

Country of Birth

Select Country

Place of Birth

Select Sate

Mother's Religion

Rite

In Case Patient Is Under 18 Years of Age Or Parents Do Not Live In The Same Place:

Parents Local Address

Country

Select Country

City

Province

Select Province

Street

Phone

Mobile

Email

Do You or Your Parents Hold a UN Refugee Status

YesNoPending

If Yes: Please Provide Copy

D- CARE MANAGER INFORMATION

Full Name of the Local Case Director

Address

Cell Phone

Email

Name of Organization

(Applies to All Representatives of Local Community or Care Providers Such as vetted Church Non Profit Organizations of Social Services: (Example: Caritas, Jesuit Services, Local Lebanese Parish Charity Organizations)

MEDICAL SERVICES ACKNOWLEDGMENT AND APPRECIATION LETTER

This letter is to acknowledge the involvement of the Apostolate of Our Lady of Hope/St. Rafka Mission of Hope and Mercy (herein after referred to as St. Rafka Mission of Hope and Mercy) in the financial aid of the:

Patient Full Name

On

Name of Hospital

Address of hospital provided medical services

Hospital Street

City

Country

Province

Hospital Office Phone

Email

Website

St. Rafka Mission of Hope and Mercy provided

to

for the services

This letter acknowledges that Amount In Dollars

was paid as a charitable gift without expectation of repayment.

St. Rafka Mission of Hope and Mercy is not a professional medical organization and relies on the expertise of

and the

to ensure that

provided the proper medical treatment.

As such, St. Rafka Mission of Hope and Mercy is not liable for any malpractice or wrong doing by

To ensure patient privacy, details of specific services rendered are not listed in this document.

This document may be seen by non-medical professionals in the operation of St. Rafka Mission of Hope and Mercy and by auditors of all legal entities in which it operates. This amount may be made public depending on the legal requirements of the entities in which St. Rafka Mission of Hope and Mercy operates.

St. Rafka Mission of Hope and Mercy sincerely wishes for the best outcome for

and (his/ her) family, and prays for their continued well being.

The Apostolate of Our Lady of Hope/St Rafka Mission of Hope and Mercy Case Management Department

adminSFB

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