Community Support Request

Thank you for contacting Passavant Area Hospital. Passavant demonstrates its support for health, wellness and fitness through sponsorship of local not-for profit events and programming. Passavant Area Hospital (PAH) receives numerous requests from community organizations for donations, sponsorships and participation in special events. As a nonprofit organization, PAH must give careful consideration to whether and to what extent these requests support our hospital’s mission.

We also strive to address our identified community priorities of obesity, mental health, and access to care. Preference will be given to supporting community programs that are improving the health status and quality of life for underserved, low income or vulnerable members of our communities.

Nonprofit 501(c)(3) organizations, tax-exempt entities and other organizations may submit a request for support a minimum of 6 weeks in advance. Completion of this application does not guarantee funding of your request. Please be prepared to submit your organization’s IRS W-9 form, you can find information regarding a W-9 form on the IRS website.

Organizations interested in support for programs consistent with this mission should submit their request using the form below. Questions can be referred to communitysupportrequest@passavanthospital.com. Forms are also available in the Marketing and Communications Office. For more information, call 217-245-9541, ext. 3129.






Contact Information

Name of Organization:
Contact Person:
Contact Phone (Work):
Contact Phone (Mobile):
Contact Email Address:
Organization Address:
City:
State:
Zip Code:

Organizational Information

1. Is your organization a 501 (c)(3) non profit or other tax-exempt organization?
 Yes No

2. Organization’s Website Address (if applicable)

3. What is your organization’s mission?

4. What cities or counties are served by your organization?

Request Information

Event/Program Name

Date

Location

Date Sponsorship Funds Needed

What type of support is requested? Check all that apply.
 Sponsorship Exhibitor Monetary Donation Giveaways Health Presentation Health Screening

What level of sponsorship are you requesting? Please include dollar amount.

Community Support Information

1. Briefly describe how your request can improve the health of our community. Include your target audience, the number of people to be served, and how you will use this donation.

2. Does your initiative specifically address or support one of Passavant’s identified community health needs? (obesity, access to healthcare, and mental health)
 Yes No

If you marked “Yes” to the previous question, how?

Passavant Area Hospital Information

1. Is anyone at Passavant on your organization’s board or involved with this initiative?
 Yes No

2. Will Passavant receive any publicity or recognition for this donation?
 Yes No

If “Yes,” please elaborate.

3. Has Passavant provided support for your organization in the past?
 Yes No

If “Yes,” please elaborate.

4. If a Passavant sponsorship/contribution is provided, the use of those dollars is to be restricted to the purpose as stated in this application. Do you accept this restriction of funding?
 Yes No

Passavant, SIU Offer Telehealth Services

Posted on: April 19, 2017

Southern Illinois University School of Medicine and Passavant Area Hospital are partnering to bring virtual health care to the residents of Jacksonville and surrounding counties. Through telehealth services, patients can visit Springfield medical specialists using videoconferencing technology at Passavant Area Hospital instead of traveling to Springfield. Patients will have access to advanced care in multiple specialties, including neurology, dermatology, infectious disease and endocrinology. An SIU telehealth virtual visit is the same as a regular face-to-face visit and, in most cases, is covered by insurance, said Dr. Nina Antoniotti, SIU’s executive director of telehealth and clinical outreach. High-definition audio and videoconferencing technology enable specialists to deliver the same level of care as in-person visits. “This partnership with SIU will allow local residents to stay close to home and use our facility to continue their care,” said Harry Schmidt, president and CEO of Passavant Area Hospital. “Patients will be guided through their telehealth visits by a clinical telepresenter who has been specially trained by SIU to ensure the process goes smoothly and patients are comfortable.” Some of the advantages of telehealth services include improved access to care, reduced time from referral to appointment, improved patient outcomes and lower out-of-pocket costs for patients. “This partnership allows us to fulfill the hospital’s mission to improve the health of the people and communities we serve by strengthening convenient access to healthcare services to residents in rural areas,” Schmidt said. “By offering access to care from a variety of specialists in a convenient location, we believe we’ll see a healthier community as a result.” SIU telehealth technology is currently installed in 12 locations throughout rural Illinois, Antoniotti said. Patients who wish to schedule an SIU telehealth visit should work with their local physicians. To help educate the public on the benefits of the technology, Passavant and SIU Medicine will host an informational community event on Wednesday, May 10, that will include a mock telehealth appointment. The event runs from 5:30 to 6:30 p.m. in Meeting Room 4 at Passavant. Call 217-479-5800 to register.

Copyright © 2015. Passavant Area Hospital. All Rights Reserved

Back to Top