INSURANCE PREMIUM PROGRAM APPLICATION CHECKLIST

Transcription

1 INSURANCE PREMIUM PROGRAM APPLICATION CHECKLIST Name of Applicant: All of the following items must be included in your application package. If they are not, processing may be delayed. Please check off each item enclosed and include this sheet in your package. Check Completed Application Document or Description A signed letter or verbal confirmation from a medical professional confirming diagnosis and treatment plan Completed HIPAA Form A signed letter from your current employer indicating your current employment or leave status (*Only if this effects eligibility due to loss of income) A copy of your driverʼs license The front page of your tax returns from the previous year (*If last year s return is not yet available, (due to IRS due dates and/or extension requests), submit the return from the previous year (i.e.: 2 years ago). If applicant does not file taxes, Verification of Nonfiling Status must be obtained. A copy of your checking and savings account statements for the last two months. Completed NCCN Distress Thermometer Documentation of health insurance premiums you wish considered for payment. MAIL OR FAX YOUR COMPLETED APPLICATION and all required documents to: Gateway to Hope 425 N. New Ballas Rd Suite 220 Creve Coeur, MO Or Fax: Or info@gthstl.org

2 GATEWAY TO HOPE PROGRAM APPLICATION NAME: TODAY S DATE: DATE OF BIRTH: AGE: MARITAL STATUS: RACE/ETHNICITY Lymphedema : ADDRESS: CITY: STATE: ZIP: COUNTY: PHONE: HOME CELL WORK/OTHER OCCUPATION: COMPANY: INSURANCE: Y N INSURANCE TYPE: #PERSONS COVERED: MONTHLY PREMIUM AMOUNT: INSURANCE COMPANY: POLICY HOLDER NAME: EMPLOYMENT STATUS: HOUSEHOLD INCOME: ANNUAL/MONTHLY SOURCE OF INCOME: # OF PERSONS IN HOUSEHOLD: TREATMENT INFO: DIAGNOSIS AND STAGE: GENETIC TESTING: (CIRCLE IF COMPLETED) BRCA 1 +/- BRCA 2 +/- BIOPSY DATE: FACILITY: (ER + / - ) ( PR + / - ) (HER2 + / - ) (PLEASE CIRCLE ) SURGERY INFO: PHYSICIAN: FACILITY: PHONE #: PROCEDURE: (LUMPECTOMY OR MASTECTOMY) (L/R/BILATERAL) DATE: RECONSTRUCTIVE SURGERY:PROCEDURE & DATE: PHYSICIAN: FACILITY: MEDICAL ONCOLOGY INFO: PHYSICIAN: FACILITY: PHONE #: TREATMENT PLAN: NEO-ADJUVANT (BEFORE SURGERY) START DATE: DATE COMPLETED: ADJUVANT (AFTER SURGERY) START DATE: DATE COMPLETED: RADIATION ONCOLOGY INFO: PHYSICIAN: FACILITY: PHONE #: # OF TREATMENTS PLANNED: START DATE: DATE COMPLETED: Thelma s REFERRAL SOURCE: NAME: TITLE (IF APPLICABLE): FACILITY (IF APPLICABLE): SOCIAL WORKER/CASE WORKER/NURSE NAVIGATOR (OPTIONAL): NAME: PHONE #: IPP Thelma s & IPP PATIENT S SIGNATURE: DATE: Patient FPG: For Office Use Only Eligibility Status: Date: Notes: Optional. Used for grant funding purposes only

3 Applicant Financial Information: Complete financial information is required on all household members Household Assets Monthly Household Expenses Checking Account. $ Rent Mortgage $ Savings Account $ Phone(s) $ Retirement Assets (e.g. 401k, IRA) $ Utilities $ Stocks & Bonds $ Transportation Auto Payment(s) $ Monthly Household Income Auto Insurance $ Take Home Pay $ Medical Expenses Spouse s Take Home Pay $ Health Insurance $ Additional Household Income $ Misc. (Specify) $ Child Support $ Misc. (Specify) $ Alimony $ Food Stamps $ SSI/SSD benefit $ Veterans benefits $ Other (Specify) $ Total Monthly Income $

4 Applicant Attestation In consideration for acceptance into the Gateway to Hope Insurance Premium Program (Program), I agree and certify as follows: 1. I attest that the information provided is complete and accurate to the best of my knowledge. 2. I have read, understand and agree to abide by the Program Guidelines. 3. I understand that while every effort will be made to provide assistance, the Program is limited to the availability of funds and I may not receive assistance even if I satisfy the eligibility requirements and the other terms and conditions in the Program Guidelines. 4. I understand the Program Guidelines could be modified at any time and the Program could be discontinued at any time. 5. I understand that GTH has the right to audit my eligibility and the accuracy of any documents or information I provide and to request that I provide any additional information. I understand that if I desire to receive assistance beyond the original grant term, I will be required to submit updated information to GTH. 6. I understand that GTH will have the right to terminate any assistance granted if GTH becomes aware that any information provided in this application is not accurate, if I do not provide any information requested by GTH or if I do not meet the eligibility requirements and other terms and conditions set forth in the Program Guidelines. 7. I will promptly notify GTH of any changes to the information I have provided to GTH. 8. I understand that I am not required to use any particular health care provider as a condition of receiving assistance under the Program and I am free to change my health care providers at any time. 9. I acknowledge that GTH may disclose certain information from my application to my health insurance carrier, breast cancer caregivers, pharmacists, or other parties to fulfill my grant request. 10. I understand that from time to time, GTH aggregates data from many patients to create aggregated (summary) patient data which GTH may share with third parties, including researchers, partners, foundations, policy makers and other funding sources to help us apply for funding, prepare reports, advocate on behalf of patients, or perform other health related research. 11. I attest that I am not receiving financial assistance for the insurance premiums for which I am applying for assistance under the Program. In the event I become qualified for Medicaid coverage and in connection therewith, or otherwise, become entitled to a refund of insurance premiums, I agree that GTH shall be entitled to receive such refunds and I will transfer any such refunds I receive to GTH immediately. 12. I understand that in no event shall GTH be liable in any way for damages alleged to result from errors or delays in the processing of Program applications or the issuance of payments as part of the Program, my choice of health care provider or the success or failure of any therapy or treatment I obtain using funds from the Program. By signing below, I attest that I have read, fully understand and agree to the Applicant attestation set forth above. Applicant's Name (Please Print) Applicant's Signature Date

5 Insurance Premium Program Premium Reimbursement Request Form Fax COMPLETE FORM and supporting documentation Demographic Information Name (First Name, Middle Initial, Last Name) Date of Birth Payee Information Make Check Payable to (Name of Person, Facility or Organization): Address for payment: Telephone Fax Insurance Premium information Coverage Period Due Date Premium Amount Due Payment Frequency (check one): Weekly Bi-Weekly Monthly Bi-Monthly Quarterly Reference Information to be printed on check (e.g. Patient s insurance member ID) To make premium payments directly to your insurance company, please submit the following along with this request form: o Insurance Invoice or Coupon indicating coverage period to be paid, due date, and premium amount To reimburse the patient/guardian for premium payments, please submit the following along with this request form: o Insurance Invoice or Coupon indicating coverage period, due date, and premium amount o Proof of Payment (submit any one of the following showing your actual payment for your premium) o Bank statement (must show account holder s name) o Credit card statement (must show account holder s name) o Pay stubs or Cancelled Checks (must be accompanied by a bank statement) o Medicare Part B deductions from Social Security, submit bank statement showing Social Security Deposit o Premium deduction from Pension, submit bank statement showing pension deposit Applicant's Declaration I verify that the information provided in this request is complete and accurate. I further verify that to the best of my knowledge the information presented in my original application for assistance through the Gateway to Hope (GTH) Insurance Premium Program has not changed. I understand that I am required to notify GTH if my financial situation, insurance status, or medical condition changes from that which is reported in the original application. I have not received any other reimbursement for the expenses for which I am seeking reimbursement from GTH, nor will I receive such reimbursement from any source (including, but not limited to, Medicaid, or any other foundations), or a health care flexible spending account. I understand that I must submit my reimbursement request as soon as possible after payment of my insurance premium and that GTH will not pay claims received more than 120 days after the payment date. Finally, I understand that GTH reserves the right at any time and without notice to modify or discontinue any or all of the programs with respect to any applicant or in their entirety, to modify the related eligibility criteria, or to terminate assistance. Applicant s Signature (REQUIRED) Date

6 AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION ( PHI ) Patient s Name: Patient s Date of Birth: I hereby request that my health care provider identified below disclose the PHI described below to Gateway to Hope in connection with my application for assistance from Gateway to Hope. Name of Health Care Provider: PHI To Be Disclosed: Acknowledgment: If my medical record contains information about drug/alcohol abuse, mental health treatment, sexually transmitted diseases, HIV/AIDS testing/treatment or any other sensitive information, I agree to its release. Check if you do not agree to release of sensitive information described herein: Do Not Agree Date(s) of Service of PHI To Be Disclosed: All dates of services, unless otherwise specified below: Revocation Right: I understand that I have the right to revoke this Authorization at any time by submitting a notice in writing to the above named healthcare provider at the address stated above and that the revocation will be effective except to the extent that action has already been taken in reliance on this Authorization. Expiration: This Authorization will expire 1 year from the date of my signature below, unless otherwise specified herein: Re-Disclosure: I understand that the information disclosed by this Authorization may be subject to re-disclosure by the recipient and no longer protected by Federal or state privacy requirements. Signature: I understand that my treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing the Authorization. By signing this document, I hereby authorize the above named provider to disclose my protected health information as specified in this document. Signature of Patient or Personal Representative Date If this Authorization is signed by the patient s personal representative, indicate such representative s authority to act on behalf of the patient:

7 NCCN Distress Thermometer for Patients SCREENING TOOLS FOR MEASURING DISTRESS Help for distress Second, please indicate if any of the following has been a problem for you in the past week including today. Be sure to check YES or NO for each. Support Services YES NO Practical Problems YES NO Physical Problems Instructions: Distress First is an please unpleasant circle the emotional number state (0-10) that that may best affect how you Child care Appearance describes feel, how think, much and distress act. It can youinclude have been feelings experiencing of unease, in sadness, worry, Housing Bathing/dressing the pastanger, weekhelplessness, including today. guilt, and so forth. Everyone with cancer has National Cancer Institute s Cancer Insurance/financial Information Service Breathing some distress at some point of time. It is normal to feel sad, fearful, Transportation Changes in urination and helpless. Telephone Work/school CANCER Constipation Feeling distressed may be a minor problem or it may be more TreatmentWebsite decisions Diarrhea serious. Extreme You distress may be so distressed 10 that you can t do the things you Eating used to do. Serious or not, it is important that your treatment team 9 Family Problems Fatigue knows how you feel. Dealing with Cancer children Support Community Feeling Swollen 8 The Distress Thermometer is a tool that you can use to talk to your Dealing with Telephone partner Fevers doctors about your distress. It 7 Ability to have children Getting around has a scale on which you circle your level of distress. It also asks about the parts of life in which you are Family health Website issues Indigestion having problems. The Distress 6 Thermometer has been tested in Memory/concentration many studies and found to work well. Please complete the Distress EmotionalCancer-Support Problems 5 Mouth sores Thermometer and share it with your treatment team at your next Depression Nausea visit. 4 Fears U.S. Health Resources Nose and dry/congested Services Nervousness Administration The Distress Thermometer helps 3 your treatment team know if Pain Sadness you need supportive services. You may be referred to supportive Website Sexual services at your cancer center 2 Worry or in your community. Supportive Skin dry/itchy services can include help from support groups, chaplains, social Loss of interest aspx in 1 usual activities Sleep workers, counselors, and many other experts. Supportive services Substance abuse can also be found through the No distress 0 support services at right. U.S. Substance Abuse and Mental Spiritual/religious Health Services Administration Tingling hands/feet concerns Website Other Problems: The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient s care or treatment. The National Comprehensive Cancer Network (NCCN ) makes no representations or warranties of any kind regarding their content, use, or application, and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN

8 NCCN Distress Thermometer for Patients SCREENING TOOLS FOR MEASURING DISTRESS Instructions: First please circle the number (0-10) that best describes how much distress you have been experiencing in the past week including today. Extreme distress No distress Second, please indicate if any of the following has been a problem for you in the past week including today. Be sure to check YES or NO for each. YES NO Practical Problems YES NO Physical Problems Child care Appearance Housing Bathing/dressing Insurance/financial Breathing Transportation Changes in urination Work/school Constipation Treatment decisions Diarrhea Eating Family Problems Fatigue Dealing with children Feeling Swollen Dealing with partner Fevers Ability to have children Getting around Family health issues Indigestion Memory/concentration Emotional Problems Mouth sores Depression Nausea Fears Nose dry/congested Nervousness Pain Sadness Sexual Worry Skin dry/itchy Loss of interest in usual activities Sleep Substance abuse Spiritual/religious Tingling in hand s/feet concerns Other Problems: The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient s care or treatment. The National Comprehensive Cancer Network (NCCN ) makes no representations or warranties of any kind regarding their content, use, or application, and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN