TMA Disaster Relief Program of The Physicians Benevolent Fund

TMA is invested in helping Texas physicians get back to caring for their patients as soon as possible. Therefore, TMA's Disaster Relief Program has been reinstated to provide financial assistance to physician practices that have sustained physical damage not covered by insurance or other sources of assistance.

If your practice is in a federally declared disaster county and you need assistance, please complete the confidential application below or click HERE to download a PDF version of this form.

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED

Certification by Applicant

I certify that I have suffered damage to my medical practice and that the information contained in this application is true and complete.

I hereby request and authorize agents of the Texas Medical Association Physicians Benevolent Fund Disaster Relief Program to review all appropriate documentation that is deemed necessary in connection with my application for assistance.

I understand that submission of an application for assistance is not an entitlement and that the Board of Trustees of The Physicians Benevolent Fund shall have sole discretion in determining whether I receive assistance.

Please check and type your name: I certify

Maximum individual grants shall not exceed $15,000. Apply early as funds are limited.

Contact Information
Name of Practice

Owner/Applicant Name
First Name
Middle
Last Name

Office Address
Street Address
City
State
Zip
Telephone (office)
Fax (office)
Email
County

Please provide your temporary contact information, if different from above:
Street Address
City, State, Zip
Telephone/Mobile
Email

Practice Information
Practice Structure	If other,
Practice Premises Are	Owned Rented/Leased monthly payment:
If not owned, name of Landlord or Property Manager
Practice Tax ID #
Texas Medical License #
Number of Physicians in Your Practice
Number of Non-Physician Staff (Pre-Disaster)

Please list all physicians in your practice, including yourself, who plan to return to practice in the affected area and will benefit from this assistance. If you have additional physicians in your practice, please email their information to disaster[at]texmed[dot]org.
Name
Street Address
City
State
Zip Code
Practice Specialty
	Owner Physician Employee

Name
Street Address
City
State
Zip Code
Practice Specialty
	Owner Physician Employee

Name
Street Address
City
State
Zip Code
Practice Specialty
	Owner Physician Employee

Name
Street Address
City
State
Zip Code
Practice Specialty
	Owner Physician Employee

Name
Street Address
City
State
Zip Code
Practice Specialty
	Owner Physician Employee

Name
Street Address
City
State
Zip Code
Practice Specialty
	Owner Physician Employee

Name
Street Address
City
State
Zip Code
Practice Specialty
	Owner Physician Employee

Name
Street Address
City
State
Zip Code
Practice Specialty
	Owner Physician Employee

Description of Needs
Briefly describe the nature and date of the disaster and provide details on the property damage sustained.
Briefly describe how you plan to use PBF Disaster Relief funds
Do you have insurance coverage for your practice facility?	Yes No
What is the deductible of your insurance policy that will provide coverage toward damages associated with this disaster?
Excluding deductible, what is the net loss after insurance coverage?
Name, address, and telephone number of insurance company
Do you have any other type of insurance to cover your losses?	Yes No
What should we know about your insurance coverage and claim status?
Please describe briefly other disaster relief assistance, if any, you have already obtained or are seeking to use in restoring or rebuilding your medical practice (provide name of agency and anticipated or received amount or value or assistance).
Please submit any other information that you feel is pertinent to understanding your application.

TMA Disaster Relief Program of The Physicians Benevolent Fund

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED

Contact Information

Practice Information

Description of Needs

Certification by Applicant