Funding Request

Comments

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Request for Cremation or Funeral Financial Assistance

This form contains conditional logic, so the options you see will update based on certain selections. Our Cremation or Funeral Financial Assistance Program is limited by our available funds. If you would like to check for funds availability before submitting the from, please contact us. We will try to update this page when funds are not available.

Not Eligible for this Form

At this time, our online form is limited to MUSC and Roper St. Francis Healthcare referred patients only. Please contact us for program available. Our program is limited to SC residents and SC hospitals.

MUSC Referral – Shortened Form

This is our MUSC Referral shortened form that does not require financial information. MUSC’s approved Financial Assistance Form must be submitted or emailed by a MUSC employee.

Person Submittng the Form

Our preference is for one of the parents to submit the form, but we know the grieving process is difficult. We understand if a trusted individual is helping the parents during this difficult time. We encourage this type of support to the parents. However, we must contact one of the parent’s to verify funding details.

Person is submitting the form is:(Required)

Organization(Required)

Title(Required)

Phone(Required)

Email(Required)

Comments

Parent(s)'s Information

Mother's Phone(Required)

Mother's Email(Required)

Phone(Required)

Email(Required)

Baby's Information

If no, Weeks of Gestation:(Required)

We do not need all of the service provider(s) details at this time. The items marked as required are the information we need at this time to be considered for conditional approval. The other information is required for final approval and can be submitted via email within 30 days of conditional approval.

Requested Financial Assistance Amount:

If yes, how will this balance be paid?

Name of Crematorium/Funeral Home:

Crematorium/Funeral Home Phone:

Crematorium/Funeral Home Email:

Name of Interment Location:

Interment Location Phone:

Interment Location Email:

Upload Invoices from Service Providers

Drop files here or

Max. file size: 480 MB.

Financial Information

MUSC Approved Financial Assistance Form