31640 U.S. Hwy 19 N. Suite #2 Palm Harbor, FL 34684

(727) 781-HERO (4376)

Healing Heroes Program Application

Healing Heroes Program

Healing Heroes Program provides financial assistance and arrangements for treatments through its nationwide network of providers.

The needed treatment or therapy must be the result of an illness or injury incurred or aggravated in the line of duty in Iraq or Afghanistan after September 11, 2001.

You must provide Healing Heroes Network with a copy of your DD Form-214 and/or your last duty orders before we can complete your application process. You can upload them now for faster processing.

* Required Information

Applicant's First Name (*)
Please type in your first name.
Applicant's Last Name (*)
Please type in your last name.
Gender (*)
Please select your gender.
Date of Birth (*)
Please select you date of birth
Street Address (*)
Please type in your street address.
City (*)
Please type in your city.
State (*)
Please select your state.
ZIP Code (*)
Please type in your ZIP code.
Phone (*)
Please type in your phone number.
E-Mail (*)
is not a valid e-mail address.
Branch of Service
Invalid Input
Current Military Status (*)
Please select your current Military Status.
Date of Injury or Illness Seeking Treatment For (*)
Please select Date of Injury or Illness
What is the Injury or Illness? (*)
Please give a description of your Injury or Illness.
Location Where Injury or Illness Occurred (*)
Please tell us where you were injured.
How Was the Injury or Illness Incurred? (*)
Please tell us how you were injured.
Service Requested (*)
Please select the Service you are requesting.
If Other, please specify (*)
Please specify, if you selected "Other"
Description of Medical History Pertaining to Injury or Illness (*)
Please give a description of your medical history.
How Did you Hear About Healing Heroes Network?
Please select how you heard about us.
If Other, please specify
If you selected "Other", please specify.

By submitting this form, I confirm that the above information is correct. I understand that completion of this form does not guarantee that the services requested will be provided.

I hereby give Healing Heroes Network permission to leave messages on my phone and to access my medical records, in accordance with HIPAA. I understand that Healing Heroes Network will not use my records for any other purpose, or give my information to another party.

Electronic Signature (*)
Please sign by typing your name.
Date (*)
Please select today's date.
Security Verification (*) Security Verification
Please enter the 4 letter security code you see
into the box.

National Charity

31640 U.S. Hwy 19 N. Suite #2 Palm Harbor, FL 34684

by phone: (727) 781-HERO (4376) - Local

by e-mail: info@healingheroes.org

or fill in the form on our contact page

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