Sometimes we all need help. Pebble provides financial support for those with diagnosed medical conditions and active/retired military personnel.
Applications will be processed within 24 – 48 business hours. Questions? Email us at firstname.lastname@example.org.
Who Is The Recipient?
Recipient Name (required)
Recipient Email (required)
Recipient Phone. Please Enter numbers only, for example: 5551231234 (required)
Are you applying on somebody's behalf? (Optional)
Caregiver Name (If Applicable)
Caregiver Email (If Applicable)
Caregiver Phone. Please Enter numbers only, for example: 5551231234 (If Applicable)
1. Is Recipient a Military Veteran? YesNo
Active Duty? YesNoN/A
List the branch and years of service:
If Active, please submit a copy of your Military ID. If not Active, please submit a copy of your expired Military ID and/or DD214 with this intake form.
Upload Military ID Document(s)
2. Does Recipient (military or not) have a Diagnosed Medical Condition (e.g. Autism, Arthritis, etc)?
If yes, then list the condition(s), treating physician(s) and the name/type of document(s) you are submitting to verify the medical condition(s). Please submit a copy of the medical document(s) you list, with this intake form.
(e.g. copy or photo of recent prescription with your name on it.)
3. If not a Military Veteran or Diagnosed with a Medical Condition, are you seeking financial assistance with Pebble purchases for another reason? Please provide details:
Please confirm you have read and reviewed "HIPAA Notice of Privacy Practices Statement"
HIPAA Notice of Privacy Practices Statement
How We Collect Information About You: Pebble Global Holdings (PGH) and its employees and volunteers collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voice mails, and from the submission of applications that is either required by law or necessary to process applications or other requests for assistance through our organization.
What We Do Not Do With Your Information: Information about your financial situation and medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voice mails), contained in or attached to applications, or directly or indirectly given to us, is held in strictest confidence.
We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services that is considered confidential, is restricted by law, or has been specifically restricted by a client in a signed HIPAA consent form.
How We Do Use Your Information: Information is only used as is reasonably necessary to process your application, provide you with a unique discount code or improve services to you which may require communication between PGH and providers necessary to verify that your medical information is accurate and determine the best Pebble products and serving suggestions for you.
If you apply or attempt to apply to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law.
Limited Right to Use Non-Identifying Personal Information From Testimonials, Biographies, Letters,
Notes, and Other Sources: Any testimonials, pictures, stories, letters, biographies, correspondence, or thank you notes sent to us become the exclusive property of PGH. We reserve the right to use non-identifying information about our clients (those who receive services or goods from or through us) for promotional purposes that are directly related to our mission.
Clients will not be compensated for use of this information and no identifying information (photos, addresses, phone numbers, contact information, last names or uniquely identifiable names) will be used without client’s express advance permission.
You may specifically request that NO information be used whatsoever for promotional purposes, but you must identify any requested restrictions in writing. We respect your right to privacy and assure you no identifying information or photos that you send to us will ever be publicly used without your direct or indirect consent.
I have reviewed the "HIPAA Notice of Privacy Practices Statement"