To apply for medical assistance, please complete the form below.  The Santa Fe Community Foundation will respond to inquiries regarding the application for medical funds, or costs associated with medical needs.

Since its inception, the Santa Fe Artists’ Medical Fund has raised money and maintains a Permanent Fund managed by The Santa Fe Community Foundation. The Permanent Fund generates income which is used for grants for medical care or costs associated with medical care. The Santa Fe Community Foundation reviews applications and makes grant decisions to avoid any inequities or conflicts of interest in distributing the funds. Funds are available for the medical needs of Visual Artists, but are not unlimited.  Grant recipients are encouraged to help replenish the Permanent Fund, when and if able. Grants in support of requests pertaining to longer-term illnesses are considered on a case-by-case basis.

The Fund can distribute money to pharmacies, hospitals, and health care providers, but not to individuals. Assistance ranges up to $2,500 but varies depending on the applicant’s circumstances. The Fund is advised by The Santa Fe Community Foundation which evaluates applications for financial assistance and determines if medical bills can be paid (partially or in full) from the Fund.

Criteria Used To Determine Eligibility

The following criteria will be used to determine eligibility:

1. Funds are available for medical purposes and the costs related to medical care to Visual Artists, whether working or retired.
2. The applicant has no health insurance or insufficient health insurance (The Fund can be used to help pay a deductible, extra medical costs not covered by insurance, or extraordinary expenses related to medical costs).
3. The applicant lives and works in northern New Mexico.
4. The applicant has submitted an application and proof of meeting criteria to The Santa Fe Community Foundation (see application below).
5.  Special cases which are not ordinarily eligible under the above guidelines will be considered on a case-by-case basis.

Documentation Required:

1. Summary of Uncovered Costs (see form below)
2. A Written Statement indicating the lack of sufficient insurance coverage for treatment (see form below)
3. Most recent income tax return or other proof of income such as form 1099, W-2, pay stubs, pension distribution or social security benefits
4. Copies of unpaid bills
5. Proof that you are a professional artist with one or more of the following: gallery representation, website, FaceBook, Instagram, Twitter, etc.

If you prefer to submit your application offline you can mail or deliver it to us in person. Print and fill out the SFAMF APPLICATION FORM pdf and deliver, with all required documentation, to The Santa Fe Community Foundation, attention Diane Hamamoto, at PO Box 1827 Santa Fe NM 87504 (mail) or 501 Halona Street, Santa Fe NM (physical address).

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Artist's Name *

First

Last

Representing Gallery

List galleries you show your work in, if any.

Website(s)

List your websites, if any.

Social Media (FaceBook, Instagram, Twitter, Etc.)

List your socials, if any.

Email *

Email

Confirm Email

Phone *

Phone 2

Mailing Address *

Address Line 1

Address Line 2

City

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Zip Code

Health Care Provider Name and Contact Information

Amount of Funds Requested *

Summary of Uncovered Costs:

+ Insurance Deductible Cost
+ Health Care Provider Fees
+ Hospital Fees
+ Labs/Imaging Costs
+ Home Medical Equipment and Supplies
+ Other Medical Expenses
= TOTAL Requested

Please add and total Summary of Uncovered Costs Below: *

List Uncovered Costs and Total them. Use as many of the above costs listed as are applicable to your situation.

Specify the medical needs or associated costs. *

Provide detail in reference to your costs related to injury/treatment that you are requesting funds for.

Provide a written statement indicating the lack of health insurance or appropriate coverage for treatment. *

State how you are in need and provide proof that you are unable to cover costs yourself.

File Upload: Add Proof of Income Here

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Attach pdf or jpeg file of up to 10 of the following: most recent income tax return, Form 1099, W-2, or other legal proof of income.

File Upload: Add Medical Bills Here

Drag & Drop Files, Choose Files to Upload You can upload up to 25 files.

Attach pdf or jpeg file of up to 25 copies of medical bills that are either unpaid or paid, but need reimbursement.

Qualifying for Medical Assistance

I pledge that the information above and attached is accurate and that providing misleading or incorrect information will be reason for disqualification.

I agree *

• Yes
• No

Submit