PATIENT/FAMILY PROFILE
To qualify for Medical Travel Assistance funds, this form must be
completed and on file with the KT
Foundation prior to the application process. Please
print this form, complete the requested information
and contact our
office for additional information.
Date:
KTS Patient’s Name and Birth Date:
Patient’s Address:
Phone Numbers:
Home:
Work:
Other:
E-mail Address:
Applicant’s Employer, Address
& Phone Number:
Spouse/Co-applicant’s Employer,
Address & Phone Number:
Patient’s Primary Care Physician’s
Name, Address & Phone Number:
List any Specialists treating
patient. Provide Names, Addresses & Phone Numbers:
Please provide as many details as
possible of your (or your child’s) medical history:
None of the information you have
provided will be shared to any individual outside the KT Foundation.
By signing this form, you agree to
give the office of the KT Foundation the right to contact you directly or
contact your employer in order for us to inquire about your insurance benefits
plan in regards to how they cover travel for medical purposes. This action will be necessary if and when you
apply for medical travel assistance funds.
Patient Date:
Parent: Date:
(if patient is a minor)
Parent: Date:
Should there be any changes in the information
that you have provided to the KT Foundation, we ask that you contact our office
either by phone at
We will be happy to send you a
new form. The KT Foundation office will
not make changes to your profile due to the opportunity for discrepancies that
may occur. In addition, you will need to
sign your profile form. Please submit
your form to:
The KT Foundation