Instructions for Completing ATL Application for Assistance:
- Fill out the entire application. Be as thorough as possible. If all of the requested information is not filled in, the process can be slowed down considerably.
- Sign the form and fill out your healthcare provider’s name, address, and phone number on page 3. Present it to your attending healthcare provider for her or his signature on page 1. (This may be your M.D., D.O., nurse practitioner or other licensed alternative care provider.)
- Have your healthcare provider write a brief statement of your diagnosis, treatment type and duration of treatment on her or his business letterhead and include it with your application.
- You, your personal advocate who is helping you fill out this paperwork, or your health care provider’s office may return the completed application by one of the methods shown below.
Call Sue Boynton at 303-667-5176 or Becky Moore at 303-884-0266 if you have any questions or need assistance filling out the application.
Please return your application by one of the following methods:
Mail: ATL Foundation, P.O. Box 17852 Golden, CO 80402
Fax: Attention: Sue Boynton at 303-948-2906
Email: firstname.lastname@example.org (scan or print to .pdf and attach application to the email)