Assistance

The Vikings of Solvang assist people in paying for medical needs if they cannot afford to pay the expenses themselves. You may be contacted to provide additional information. Except in an emergency, the Charity Committee reviews and recommends an action to be taken regarding your request. Requests are processed on a monthly basis.

Please download the HIPAA Form, fill it out, and submit it with your request for assistance.

HIPAA Form


    Personal Information

    Name (required)
    Address (required) How Long
    Email (required)
    Phone (required) DOB (required)
    Parent/Guardian

    Additional Information

    Employer
    Insurance
    Doctor Last Visit

    How Can We Help You?

    Tell us about your medical condition and/or diagnosis and how we can best serve you:
    Please attach any supporting documentation to justify your request.

    How Did You Hear About Us?

    Method referralprint adother

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