Application Checklist and Forms

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Emory Norris
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1 Application Checklist and Forms Please check off each item enclosed with your application. All items are required. Incomplete applications will not be accepted. Mail your completed application and all required documents to: The Pink Fund PO Box 603 Bloomfield Hills, MI Please note: Applications sent by fax or will not be accepted. Completed Pink Fund Application Send all 8 pages of this application. Application Checklist and Forms Application for Financial Assistance Medical Information (2 pages) HIPAA Privacy Authorization Form Bills Requested for Funding Financial Disclosure Form Media Release and Waiver (optional) A signed letter (on letterhead) verifying your current diagnosis and detailing your treatment plan from one of the following: Oncologist Patient Advocate Licensed Social Worker Nurse Navigator Please make sure you include an address for your Social Worker, Patient Advocate or Nurse Navigator on page 3 of this application. A signed letter from your current employer (on company letterhead), verifying your current employment or leave status. A copy of your driver s license or State ID Please note: the address on your ID must match the address on your application form. The front page of your tax return from the previous year W-2s or 1099s from the same year of your tax return A copy of your last 2 paycheck stubs A complete copy of all your checking and savings account statements for the last 2 months for you and your spouse or partner. Copies of ALL bills you wish considered for payment. Please DO NOT send originals. The bills must show your name, or the name of your spouse or partner, your current address, the account number, the current balance due, and the complete address to which payments are sent. Bills considered for payment: Car Insurance Premiums Car Loans Health Insurance Premiums Mortgage/Rent* Phone Bills Utility Bills *IF YOU RENT, you must send a complete copy of your lease/rental agreement, including the name and address of the person or agency to which payments are made. We must have a current address at which to contact you. If you do not have an address, our communications will be through U.S. Mail and will delay the processing of your application. Please understand we are not an emergency fund and cannot provide immediate assistance. All decisions are made on the 3 rd Monday of each month by our Qualifications Committee based on guidelines set forth by our Board of Directors. Incomplete applications will not be accepted. Page 1

2 Application for Financial Assistance Personal Information: Name: Date of Birth: / / Street Address: Ethnicity: City: State: Zip: Phone: Preferred method of contact: Best time to reach you: Educational Level: Post-Graduate College Degree High School Grade School Marital Status: Single Married Divorced Widowed Partnered Separated Please list all the people in your household: Name: Relationship: Wage Earner: (Y/N) Age: Self How did you hear about The Pink Fund? Employment Information: Company Name: Employment Status before your breast cancer diagnosis: Hourly Salary Full-time Self-employed Part-time Unemployed Current Employment Status: Hourly Full-time Self-employed Disability/sick leave If on disability/sick leave are you receiving any compensation? Yes / No If Yes, amount received: $ (Weekly / Monthly) Number of Months: Date you last worked: / / Insurance Information: Do you have disability insurance (Not Social Security Insurance Disability)? Yes / No If Yes, state waiting period Salary Part-time Unemployed FMLA Amount received: $ (Weekly / Monthly) Number of Months: Health Insurance: None Medicare Medicaid Provided by Employer/Spouse s Employer Private Page 2

3 Medical Information Please have this page filled out by your Oncologist, Licensed Social Worker, Patient Advocate or Nurse Navigator verifying your current diagnosis and detailing your treatment plan. Form completed by: Oncologist Licensed Social Worker Patient Advocate Nurse Navigator Applicant Name: Hospital: Current Diagnosis: Date Diagnosed: Stage/Grade: Type: In-Situ Invasive Ductal Carcinoma Inflammatory Recurrent Metastasis Paget s Lumpectomy Date: Mastectomy Date: Reconstruction Date: Chemotherapy: Start Date: Projected End Date: Radiation: Start Date: Projected End Date: Other therapy or treatment details: Signature Name (please print) Title Date Signed Phone Page 3

4 Medical Information Please provide the name, address, and phone number for the following providers. We may contact them if we can t reach you or need further information. NAME POSITION ADDRESS PHONE Surgeon Oncologist/Oncology Nurse Social Worker Other Please read the statements below and initial where indicated. I understand The Pink Fund does not pay for medical expenses of any kind. I am currently a breast cancer patient either recovering from a mastectomy/lumpectomy, and/or I am currently undergoing chemotherapy or radiation. I give my full authorization and permission to The Pink Fund to obtain the necessary medical information to process my application. I understand The Pink Fund may ask personal questions about my treatment and financial status; I agree to provide accurate answers. I understand a representative of The Pink Fund will be performing a follow-up survey. I understand The Pink Fund is not liable for any cost incurred in the submission of this application for financial support. I understand my application will be held for 7 years in accordance with The Pink Fund s retention policy and will not be returned. Applicant s Signature: Date: You must also complete the HIPAA Authorization Form, Bills Requested for Funding, Financial Disclosure Form, and provide all documents requested. Incomplete applications will not be accepted. Page 4

5 HIPAA Privacy Authorization Form Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R., Parts 160 and 164). AUTHORIZATION I (print name) hereby authorize (your treating physician or hospital) to disclose the protected health information described below to The Pink Fund. EFFECTIVE PERIOD This authorization for release of protected health information covers the period from (DATE) to and through (DATE). EXTENT OF AUTHORIZATION I authorize the release of my protected health information only as it pertains to my breast cancer diagnosis and treatment. This medical information may be used by The Pink Fund for the purpose of evaluating my eligibility for financial aid according to its guidelines or for other purposes as I may direct in writing. This authorization shall be in force and effect until (DATE), at which time this authorization expires. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. I understand that any information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. Signature of (check one): Patient Personal Representative Signature Date Printed Name of Patient or Personal Representative Page 5

6 Bills Requested for Funding Applicant Name: Please list the bills you would like considered for payment below. Please include a COPY of all bills you wish considered for payment. DO NOT send originals. In order to be considered for payment, the bills must show all of the following: Your name (or the name of your spouse or partner) The current balance due Your current address The complete address to which payments are sent The account number IF YOU RENT, you must send a complete copy of your lease/rental agreement, including the name and address of the person or agency to which payments are made. Note: The Pink Fund does NOT pay credit card accounts or medical bills other than health insurance. Bills to be considered for payment: Mortgage/Rent Gas Electric Car Payment Car Insurance Bill Type Paid To Monthly Amount Health Insurance (includes COBRA) Other: Other: Any additional information: Please list any other organizations to which you have applied for assistance. Our intent is to maintain a list of additional resources for our applicants. Page 6

7 Financial Disclosure Form Applicant Name Detail 401(k), Roth IRA, Retirement, Pension, and Bonds/Stocks totals Total Savings / Checking Account totals Monthly Income Self Before Diagnosis Self After Diagnosis Partner Total Salary Social Security Disability and/or State Disability Workers Compensation Veteran s benefits / Armed Services allotment Pension and/or annuity payment Alimony Child support Interest / Dividends from assets / Gross rent from properties Disability policy benefits or sick pay from employer Money from friends or family Total Monthly Income Expense Monthly Amount Expense Monthly Amount Mortgage/Rent Auto Loan Health Insurance Utilities Home Insurance Auto Insurance Life Insurance Child Support Internet / Cable Telephone Groceries Total Expenses: Please list any additional monthly expenses and amounts on a separate sheet. Page 7

8 OPTIONAL APPLICANT MEDIA RELEASE AND WAIVER (Referred to herein as the "Release") I, hereby grant The Pink Fund, its agents, philanthropic, community and business partners, subsidiaries and affiliates, and their respective licensees, successors and assigns (referred to collectively herein as "The Pink Fund") the right to use, disclose, maintain, copy, publish, transmit, copyright and permit others to use my image, likeness, name, and personal information, including my story about The Pink Fund and the grant that I received (the "Content"), for commercial or noncommercial purposes, including advertising, public relations, promotion of The Pink Fund, its products and services and its partners or affiliates. This right shall be perpetual throughout the world, and extend to any medium or format whatsoever (existing or yet-to-be created), including without limitation, in and on magazines, brochures, and other print publications, content displayed in The Pink Fund's corporate offices, press releases, electronic media, and the internet (including the website and social media sites of The Pink Fund and its partners). I transfer and assign to The Pink Fund my entire right, title and interest in the Content and agree that all Content used by The Pink Fund in any manner is owned by The Pink Fund. I agree that I have no right to review or approve Content before it is used by The Pink Fund and The Pink Fund shall be without liability to me for any editing, distortion or illusionary effect resulting from the publication of the Content. The Pink Fund has no obligation to use the Content. I further agree and do hereby release and hold harmless The Pink Fund from any and all claims, actions, suits, liabilities or damages arising from use of the Content, and whether resulting from the negligence of The Pink Fund or any other person. I waive any right I may have to make or bring any claim against The Pink Fund relating to its use of the Content. I understand and agree that I will not be compensated in any way for providing the Content to The Pink Fund or authorizing its use in the manner detailed herein. I HAVE CAREFULLY READ, CLEARLY UNDERSTAND AND VOLUNTARILY ACKNOWLEDGE THE INFORMATION SET FORTH IN THIS RELEASE FORM. I UNDERSTAND THAT THIS FORM PROVIDES THE PINK FUND WITH MY ABSOLUTE AND UNCONDITIONAL CONSENT, WAIVER AND RELEASE OF LIABILITY, ALLOWING THE PINK FUND TO PUBLICIZE PRIVATE INFORMATION ABOUT ME. BY SIGNING THIS RELEASE FORM, I UNDERSTAND IT HAS NO BEARING ON ANY DECISIONS MADE BY THE QUALIFICATIONS COMMITTEE REGARDING FINANCIAL ASSISTANCE. Date: Applicant Name Witness Name Signature Signature Address Address City, State, Zip City, State, Zip Page 8

FINANCIAL ASSISTANCE PROGRAM

Financial Assistance Application FINANCIAL ASSISTANCE PROGRAM As part of our mission, Benefis Health System (including Benefis Hospitals in Great Falls and Benefis Teton Medical Center in Choteau) is committed