Celebration of Life Sponsorship Forms Checklist

The following is a checklist of forms that you must have completed and returned for review of eligibility. We request that you send via USPS postmarked by September 6, 2010 the signed and completed paperwork to:

Monica Ashcraft
Honea, Houserman and Long PC
2006 Brookwood Medical Center Drive, Suite 508
Birmingham, Alabama 35209

Please print forms and sign prior to sending. Do not electronically sign completed forms.

Please do immediately:
Medical Release Form (mail to your current OB/GYN physician[s])

Please complete, sign and return:

• Application
• Female Patient History
• Male Patient History
• Preconception Questionnaire
• Answering Machine Consent
• Release of Results (Male and Female)
• HIPAA Privacy Notice (send only signed page 5)
• Your Written Essay (500 words or less)

Please send with your completed paperwork:

1. Insurance Card (Patient and Partner) (we would prefer you send copies of front and back of all cards along with your paperwork)
2. Driver’s License (Patient and Partner)
3. Year 2009 Income Tax Return

Please Remember

1. Discontinue smoking
2. Limit/decrease your caffeine intake to one cup (coffee, tea, cola, etc. ) per day
3. Begin a multi-vitamin, which contains at least 0.4 mg folic acid (females)

Back to letter