Stevie JoEllie’s Cancer Care Fund c/o Wilma Colon Ariza, Founder 649 McBride Avenue Suite No. 1 Woodland Park, NJ 07424 Email: email@example.com Tel. 973.619.9360 APPLICATION FOR FINANCIAL ASSISTANCE IMPORTANT NOTICEThis application is your request for an “Access to Care Grant” or “Essential Needs Assistance”Unfortunately, submitting an application does not guarantee funds will be available to assist you.Please be advised that our grants area based on a needs assessment and availability of funds. Wewill make every effort to assist you, and in some cases will help you access other programs andservices you may be entitled to, through collaborative partnerships and referrals to other patientcare assistance agencies. All applications must be fully compliant with all applicationrequirements before they can be accepted for consideration by SJCCF. Keep a copy for yourrecords. 1. All applications for assistance will be accepted between April and October each year. 2. Only complete, “legible” applications containing ALL required information, bill copies and other necessary documentation will be considered for assistance. 3. Applications with incomplete sections, and/or missing supporting documents will be returned to sender. Applications we cannot read will also be returned. 4. If you are requesting “Essential Needs Assistance” you must include a copy of the bill you need assistance with and Section 6 must be completed by a Social Worker (not an “intern” or volunteer) from a local community assistance agency. 5. Essential Needs Assistance Grants are paid directly to service provider only. 6. Section 7 must be completed by your doctor –not office manager, secretary or nurse. 7. Due to limited staff and funding sources it may be a month or more before we can review your application for services. 8. In some cases will help you access other programs and services you may be entitled to, through collaborative partnerships and referrals. 9. Mail completed applications to the address that appears aboveStevie JoEllies Cancer Care Fund is a Project of United Charitable Program Inc., a 501(c)(3) Public Charity Tax ID # 20-4286082Program #102442 Donations are tax deductible as allowed by law and all funds raised by Stevie JoEllies Cancer Care Fund arereceived by United Charitable Programs and become the sole property of UCP, which, for internal operating purposes, allocates thefunds to the Project (SJCCFThyNet). The Program (SJCCFThyNet) Manager makes recommendations for disbursements which arereviewed by UCP for approval.
Stevie JoEllie’s Cancer Care Fund c/o Wilma Colon Ariza, Founder 649 McBride Avenue Suite No. 1 Woodland Park, NJ 07424 Email: firstname.lastname@example.org Tel. 973.619.9360 APPLICATION FOR FINANCIAL ASSISTANCEDate:________________ Section 1: Patient Information PLEASE PRINTLast Name:_____________________________ First Name:_______________________________Address:_________________________________________________________________________City______________________________________State_____________Zip Code______________Home Phone_______________________________ Mobile________________________________Work Phone_______________________________ Email__________________________________D.O.B.________________ Age________ Sex: Male ( ) Female ( ) Transgendered ( )If patient/applicant is a minor please indicate name of parent or guardian 1. Have you applied for assistance from Stevie JoEllie’s Cancer Care Fund before? No ( ) Yes ( ) If yes, Date ______________ Program: Access to Care ( ) Essential Needs ( ) 2. Did you receive assistance from Stevie JoEllie’s Cancer Care Fund? No ( ) Yes ( ) If the answer is yes, please state date______________Amount_________ 3. If SJCCF provided referral services ONLY please briefly describe referral results__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Prior grant assistance recipients are encouraged to wait 90 days before new re-application
Stevie JoEllie’s Cancer Care Fund c/o Wilma Colon Ariza, Founder 649 McBride Avenue Suite No. 1 Woodland Park, NJ 07424 Email: email@example.com Tel. 973.619.9360 APPLICATION FOR FINANCIAL ASSISTANCE Section 2: Financial InformationA. FAMILY ASSETS AND EXPENSES: (please attach the following supporting documents) Copies of current bill statements for items below that you would like SJCCF to consider paying. Family Assets Verification: Include most recent bank statements for 2 months for all household members. Income Verification: Last 4 pay stubs or 2 Month Business Income Statement. DO NOT SEND TAX RECORDS. If unemployed please provide unemployment award notice or termination of benefits verificationMonthly Expenses Amount Totals Family Assets Amount TotalsHealth Insurance Premiums $ Checking Account $Medical Bills $ Savings Account $Prescription Costs $ Certificate of Deposit $Transportation $ Money Market Acct. $Child Care $ Stocks $Mobile Phone $ Bonds $Mortgage/Rent $ IRA $Home: Electric $ 401K $Home: Gas $ Income Property $Home: Water $ Business Income $Home: Phone $ Other (specify) $Home: Cable $ $Average Food Cost $ $MONTHLY EXPENSES TOTAL $ FAMILY ASSETS TOTAL $
Stevie JoEllie’s Cancer Care Fund c/o Wilma Colon Ariza, Founder 649 McBride Avenue Suite No. 1 Woodland Park, NJ 07424 Email: firstname.lastname@example.org Tel. 973.619.9360 APPLICATION FOR FINANCIAL ASSISTANCE B. INCOME SOURCES: Please Check All That Apply and Provide Copies of Appropriate Supporting Documents( ) Social Security Retirement ( ) Short Term Disability Benefits ( ) Retirement Pension( ) SSD -Social Security Disability ( ) Sick Leave Pay ( ) Alimony( ) SSI -Supplemental Security Income ( ) Employment Wages ( ) Child Support( ) Public Assistance ( ) Unemployement Benefits ( ) Family & Friends Support( ) Homeless Shelter ( ) Other (Explain)Total Household Dependents: _______ Adults:___ Children:___ Infants:___ Elderly____Total Monthly Family Income From All Sources: _____________________Are You or Your Spouse Currently Employed? Yes ( ) No ( ) If yes please answer the following:Employer:_____________________________________ Length of Employment________________Position:______________________________________ Union Member? Yes ( ) No ( )Where else have you applied for assistance? ___________________________________________________________________________________________________________________________Are you now or will you be receiving assistance from another organization(s)? Yes ( ) No ( )If yes please provide details or contact name and number of organization or casemanager below________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________If you were denied assistance by another organization or agency please briefly explain why below________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Stevie JoEllie’s Cancer Care Fund c/o Wilma Colon Ariza, Founder 649 McBride Avenue Suite No. 1 Woodland Park, NJ 07424 Email: email@example.com Tel. 973.619.9360 APPLICATION FOR FINANCIAL ASSISTANCE Section 3: Health Insurance InformationDo you have health insurance? Yes ( ) No ( ) If yes, please indicate type of insurance below You must check all that apply( ) Medicaid HMO ( ) Medicare Only ( ) VA Health Benefits( ) Medicaid Direct Access ( ) Medicare & Medicaid ( ) Private Insurance PPO( ) Medicaid Medically Needy ( ) Medicare & Supplement ( ) Private Insurance HMO( ) Medicaid Pending ( ) Charity Care Program ( ) Health Exchange NetworkAre prescription drugs covered under your healthcare policy? Yes ( ) No ( )If YES, are out of pocket expenses like your prescription insurance deductible and prescription co-pays and/or prescription medications not covered by your insurance listed in Section 2, underFamily Expenses & Medical Bills? Yes ( ) No ( ) Section 4: Essential Needs Assistance Section (Non-Medical Only) 1. Please list the exact needs for which you are requesting assistance, include costs and attach bills. Please continue to pay your bills or negotiate bill reduction and late payment until you hear back from us about your application. If you have any questions please call our office. 2. Please Note: we do not provide mortgage, rent, utility bill payment or food assistance.Essential Need Item Cost Comments
Stevie JoEllie’s Cancer Care Fund c/o Wilma Colon Ariza, Founder 649 McBride Avenue Suite No. 1 Woodland Park, NJ 07424 Email: firstname.lastname@example.org Tel. 973.619.9360 APPLICATION FOR FINANCIAL ASSISTANCE Section 5: Signature of Applicant or Person Completing Application I certify that to the best of my knowledge the information contained in Sections 1, 2, 3, and 4 of this application is accurate and complete. I hereby give permission for applicant’s Essential Needs Assessment information requested in Section 6 and medical information requested in Section 7 of this form to be released and shared with Stevie JoEllie’s Cancer Care Fund pursuant to this request for financial and referral assistance from said agency. Signature:___________________________________ Dated: _______________________ Printed Name:______________________________________________________________ Relationship to person applying for assistance: Self ( ) Spouse ( ) Parent ( ) Guardian ( ) Friend ( ) Caregiver ( ) Other ( ) Specify__________ Section 6: Referral Agency or Social Worker Contact Information Please PrintName: ______________________________________ Title_______________________________Organization Name_______________________________________________________________Address____________________________________City________________State_____Zip______Phone ( ) __________________ Fax ( ) ______________ Email___________________________Are you providing other services to this client other than assistance with this application? No ( )Yes ( ) Please Explain ______________________________________________________________________________________________________________________________________________________________________________________________________________________________Signature: ____________________________________ Dated_________________________
Stevie JoEllie’s Cancer Care Fund c/o Wilma Colon Ariza, Founder 649 McBride Avenue Suite No. 1 Woodland Park, NJ 07424 Email: email@example.com Tel. 973.619.9360 APPLICATION FOR FINANCIAL ASSISTANCE Section 7: MEDICAL VERIFICATION FORM Must be completed by Endocrine Specialist or OncologistDate of Thyroid Cancer Diagnosis____________________ Newly Diagnosed ( ) Recurrence ( )Type and Stage of Thyroid Cancer: __________________________________________________Active Thyroid Cancer Treatment: Yes ( ) No ( ) If the answer to whether this patient is in activetreatment is YES, please indicate type of treatment below. Please check all that apply.( ) Diagnostic Laboratory ( ) Hormone Replacement ( ) Bone Marrow Transplant( ) Diagnostic Imaging ( ) Chemotherapy ( ) Stem Cell Transplant( ) Surgical Follow Up ( ) External Beam Radiation ( ) Clinical Trial( ) Radioactive Iodine ( ) Additional Surgery ( ) Palliative CareIf the answer to whether patient is in active treatment is NO, is post treatment follow up needed?Yes ( ) No ( ) If the answer to whether post treatment follow up is needed is YES, pleaseindicate type of follow up: Monthly ( ) Every Six Months ( ) Yearly ( ) Other ( ) Please explain:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Doctor Name (please print) __________________________________________________________MD License #___________________Clinical Specialty____________________________________Hospital/Clinic / Facility or Practice Name_______________________________________________Address______________________________City ___________________State______Zip________Email______________________________Phone__________________ Fax___________________Doctor Signature______________________________________________ Dated_______________