Become A Recipient

Preliminary Intake Form

  • Personal Information

  • Health Information

  • Medical Insurance

  • Medical Debt

  • Social Media

  • Disclaimer

    By submitting this form, you are stating that everything you have documented above is true and accurate. You understand that your story will only be posted on the Sink or Swim Philadelphia website and social network pages for 30 days. All monetary assistance received by the recipient’s post will be sent directly to the treating facility, billing company or other specified agency within 30 days of the posting being taken off the site. In certain circumstances, SOS will send donations directly to the recipient - this will be the sole decision of SOS. If donations come in for the recipient after the goal has been reached, they will be directed toward future recipients whose goals are not met and/or held in the SOS general fund. SOS administrators have the right to accept or deny any claims submitted or remove recipient claims from the SOS website or social network pages at any time. No guarantees will be made by SOS Philly on how much monetary aid you will receive toward your medical expenses and all monetary aid will be based solely internet-directed donations made by web-donors to the recipient's SOS account set up in your name by SOS Philly. The goal amount set will be based on a percentage of your total medical debt or your total monthly medical debt as stated above. SOS Philly administrators have the right to accept or deny any claims submitted and/or to remove your story from the SOS website and social network pages at any time. Before SOS Philly can post your story we will need verification of your medical debt via copies of your most recent medical bills along with the contact information of the billing agency. SOS Philly will call your billing agency, medical facility or insurance company to verify your claim of medical debt, and if necessary, verify insurance status. A HIPAA waiver form will need to be signed and sent back to SOS Philly prior to SOS Philly being able verify your claim or to post your story on our social network pages or the website. If your story is posted on the SOS Philly sites, your cooperation with the Q&A sessions, testimonials and "sharing" of the Sink or Swim Philadelphia page is appreciated and recommended. By signing this you understand that Sink Or Swim Philadelphia will post your picture, first name and story (that you will provide and approve prior to posting) on the Sink or Swim Philadelphia social network pages, SOS Philly website and other social network pages and websites as SOS Philly deems relevant to increase donor awareness. 10% of money raised (after PayPal fees) may be reserved by SOS Philly to cover costs.