Patient Application

Note: Only a medical provider that is a member of the San Mateo Medical Center network of clinics, including those located offsite from the main campus, can fill out forms on behalf of patients.

You can submit a HIPAA compliant application on behalf of a patient by clicking the button below. If this is the first time you are submitting an application, please review the information included.

Click here if the button does not load.

Program Information and Tutorial

  • You can learn about the program, eligibility requirements, and application process by viewing this PowerPoint.

  • Check back soon for the program training video.

Frequently Asked Questions (FAQ)

Who qualifies for support from the Caring Hands in Health program?
To align with IRS regulations, program recipients must constitute a "charitable class" (e.g., individuals
facing economic hardship or children) and meet the program eligibility requirements,
which are specific to San Mateo County Health Foundation’s cause and work to identify individuals
most in need of assistance. The Caring Hands in Health program eligibility requirements:

  • Recipient must be a patient or patient guardian of San Mateo County Health facilities - must possess a MR Number

  • Recipient must live in San Mateo County

  • Recipient must be referred to by one of our providers who has attested to the needs of the patient or patient guardian

Who can submit an application on behalf of a patient?
The program application should be completed by a San Mateo Medical Center or clinic healthcare provider via the online application page. Patient consent via signature must be included at the time of submission via the application form.

Can a patient who is under the age of 18 apply for assistance from the program?
Yes, applications can be submitted on behalf of patients of any age. If a patient is under 18 years old, a parent or guardian is required to give their consent and sign the program application at the time of submission. Applications of patients under 18 years old that do not include a guardian’s signature will not be considered. 

Where can a provider submit an application on behalf of a patient?

A provider can submit the HIPAA compliant application at this link

Can a patient apply for support through the program multiple times?
Patients can apply and receive assistance up to three times per year; the third application must be reviewed by our Board before it is approved.

How long does the application process take once an application is submitted?
Applications are processed weekly by Foundation staff, and patients are notified of their application status within one week of submission.

How do I obtain a patient’s permission if they are being treated virtually?
In cases where the patient is being treated virtually, providers can attest on the application that they have been given consent by the patient or individual authorized to consent on behalf of the patient.

How do patients find out if their application has been approved?
Foundation staff will notify patients of their application status within one week of submission. In situations where the Foundation is unable to contact patients or patient guardians, we will contact San Mateo Medical Center or the submitting clinic for additional support to reach the patient.

Once approved, how do patients obtain their assistance from the program?
When notifying patients regarding the approval of their application, the San Mateo County Health Foundation staff member will arrange the pick-up location or delivery of the assistance. In situations where patients are unable to collect their assistance, a member of the San Mateo County Health Foundation will deliver the assistance to the patient or patient’s guardian at a predetermined location.


Still have questions about the program or need further assistance submitting an application? Please contact the San Mateo County Foundation team at

Thank you for helping us build this program. It is thanks to providers like you and programs like these that 77,000 patients a year can receive healthcare regardless of ability to pay. You can further support the program by making a donation.