APPLICATION FOR FINANCIAL ASSISTANCE

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THE FINANCIAL ASSISTANCE PROGRAM OF THE QUEBEC BREAST CANCER FOUNDATION Reserved for administration Application received: / / APPLICATION FOR FINANCIAL ASSISTANCE All expenses which occurred prior to

1 THE FINANCIAL ASSISTANCE PROGRAM OF THE QUEBEC BREAST CANCER FOUNDATION Reserved for administration Application received: / / APPLICATION FOR FINANCIAL ASSISTANCE All expenses which occurred prior to diagnosis OR more than 6 months before application is submitted will be excluded. Make sure you have read the Program Overview Document before completing this form. Send your application with all the required documentation using one of the following methods: a) By to soutien@rubanrose.org; b) By fax at c) By regular mail to: The Financial Assistance Program of the Quebec Breast Cancer Foundation 1155 René-Lévesque West Blvd, suite 1705, Montreal, Quebec H3B 3Z7 IS THIS YOUR FIRST APPLICATION FOR FINANCIAL ASSISTANCE FROM THE QUEBEC BREAST CANCER FOUNDATION? YES 1. PERSONAL INFORMATION NO First Name: Last Name: Date of Birth: Address: Apt: City: Province: Quebec Postal Code: Home Phone: ( ) Mobile: ( ) Civil status Married Common law spouse Widowed Single Divorced/Separated Number of dependants under the age of 18: Age of the dependants: ~ 1 ~ Nov 2016

2 2. CURRENT FINANCIAL SITUATION Section 2 must be completed only if it is a first application or if your situation has changed since your previous application. 2.1 Current sources of income CURRENT SOURCES YOU YOUR SPOUSE Employment Employment Insurance Salary insurance Disability benefits Retirement benefits Retired since: Welfare Social security recipient since: In the past 12 months, have you received financial assistance from any other community organization? Other, please specify: 2.2 Are you currently employed? ON LEAVE NO YES Last day of employment Last day of employment Full time Part time Job title Title at previous position Current title Reason for leaving Reason for leaving Are you self-employed? YES NO Expected date of return ~ 2 ~ Nov 2016

3 3. YOUR HEALTH SITUATION Section 3 must be completed by the oncologist, primary nurse or social worker. To be completed only it it s your first application or if your situation has changed since your previous application. Date of breast cancer diagnosis: Stage (if known): Metastasis: Bone Brain Liver Lung Lymph glands Others (please specify: ) If this is a relapse, please indicate date of relapse: TREATMENTS RECEIVED OR IN PROGRESS Chemotherapy DATES Currently receiving Start date: Treatments completed End date: TREATMENT LOCATION Radiation therapy Surgery: Partial mastectomy Radical Breast reconstruction Tissue Implant Currently receiving Start date: Treatments completed End date: Date: Date: Date of return to work (if applicable): MUST BE SIGNED BY THE ONCOLOGIST, PRIMARY NURSE OR SOCIAL WORKER FULL NAME TITLE INSTITUTION DATE / / Year Month Day TELEPHONE - - EXT. MANDATORY SIGNATURE ~ 3 ~ Nov 2016

4 4 -A EXPENSES FOR WHICH YOU ARE SEEKING FINANCIAL ASSISTANCE ASSISTANCE WITH EVERYDAY EXPENSES (grocery, rent, mortgage, etc.) AM I ELIGIBLE? I am currently on leave OR I have considerably reduced my hours of work due to breast cancer, which significantly decreased my family income. AND I am currently in treatment OR it has been 12 months since chemotherapy or radiation therapy OR 6 months since mastectomy and/or tissue reconstruction OR 3 months since implant reconstruction. *If you are not eligible for this type of expenditure, please skip to the next page. LIVING EXPENSES REQUIRED DOCUMENTATION I request a refund of $500 for living expenses (groceries, rent, etc.) Proof of current income and spouse s income, if applicable. e.g. salary insurance, Employment Insurance, welfare, etc. You DO NOT have to attach invoices, receipts, etc. ~ 4 ~ Nov 2016

5 4- B EXPENSES FOR WHICH YOU ARE SEEKING FINANCIAL ASSISTANCE Please attach documents. TYPES OF ELIGIBLE EXPENSES DURING CURATIVE OR PALLIATIVE TREATMENTS (surgery, chemotherapy, radiation therapy) AND DURING POST-TREATMENT RECOVERY (from 6 to 12 months, based on your particular situation). EXPENSES RELATED TO BREAST CANCER AND COMPLICATIONS OF BREAST CANCER REQUIRED DOCUMENTATION Travel Complete appendix 1 Parking Meals (at the hospital s cafeteria) Accommodations during treatment Medical assistance / housekeeping (max. $10/hour) Hairpiece, hat or scarf (max. $100/12 months) Oncology massage therapy (max. 5 sessions at $65/session) Copy of receipts Copy of receipts Copy of receipts Copy of receipts Copy of receipts Copy of receipts ELIGIBLE EXPENSES UP TO 3 YEARS AFTER THE END OF ACTIVE TREATMENTS Medication related to breast cancer not covered by the Régie de l assurance maladie du Québec (RAMQ), or group or personal insurance plans Breast prosthesis (max. $350/12 months) Specialized undergarments (max. 2 postoperative bras/12 months at $80/bra) Treatments for lymphedema related to breast cancer Copy of detailed receipts from pharmacist Copy of receipts Copy of the RAMQ reimbursement form A medical note attesting that the lymphedema is a direct consequence of breast cancer Physiotherapy, massage, lymphatic drainage (max. 20 treatments at $65/treatment) Lymphedema compression garment (max. $400/12 months) Copy of detailed receipts Copy of the RAMQ reimbursement form ~ 5 ~ Nov 2016

5. ATTACHMENTS CHECKLIST ALL ITEMS ARE MANDATORY (additional documents may be requested) FOR FIRST APPLICATION Proof of Canadian citizenship or permanent residency (birth certificate/baptismal

of breast cancer (if different) i. This document is sent to you after filing your tax return; it confirms that the return was properly completed and filed. ii.

6 5. ATTACHMENTS CHECKLIST ALL ITEMS ARE MANDATORY (additional documents may be requested) FOR FIRST APPLICATION Proof of Canadian citizenship or permanent residency (birth certificate/baptismal certificate, Canadian citizenship or permanent residency card) Copy of your completed provincial or federal tax assessment for the most recent fiscal year, AS WELL AS the year preceding the diagnosis of breast cancer (if different) i. This document is sent to you after filing your tax return; it confirms that the return was properly completed and filed. ii. A T4 slip or your tax return is NOT sufficient to satisfy this requirement. Copy of your spouse s completed provincial or federal tax assessment for the most recent fiscal year, AS WELL AS the year that precedes the diagnosis of breast cancer (if different). FOR ALL APPLICATIONS If your application is in connexion with: A everyday expenses (groceries, rent, etc.) Proof of your current income and your spouse s current income, if applicable. (employment income, Employment Insurance, disability benefits, welfare, old age pension, retirement benefits, etc.) B expenditures related to breast cancer or its side effects All detailed receipts for expenses for which you are seeking assistance. 6. SIGNATURE REQUIRED I hereby confirm that the information above is true and complete. I understand that this document, its contents and the attached information will be used solely for opening a file so that the Quebec Breast Cancer Foundation can provide me with financial assistance. I also understand that fraudulent applications for financial assistance are very costly to the Quebec Breast Cancer Foundation and deprive individuals in need of essential assistance. I hereby authorize the Quebec Breast Cancer Foundation to contact the members of my medical team. MANDATORY SIGNATURE Please sign every time you fill out an application! Date: ~ 6 ~ Nov 2016

7 APPENDIX 1 REQUEST OF REIMBURSEMENT FOR TRAVEL FOR RECURRENT MEDICAL APPOINTMENTS/TREATMENTS RELATED TO BREAST CANCER Eligible travel expenses: from home to treatment facility and back Please attach receipts. By car: 15 /km By public transit (official receipts required) Expenses related to voluntary accompaniment services (detailed official receipts required) Taxi (only when absolutely necessary). Half of the expenses could be eligible (official receipts required) *This reimbursement only applies for current or imminent active treatments and appointments during the posttreatment year. **We do not reimburse travel for visits related to secondary effects of breast cancer. ***If treatments take place beyond 200 km of your home, please refer to your Centre intégré universitaire de santé et de services sociaux (CIUSSS) for information about their policy regarding traveling for treatments. Dates Reason for travel Location (name and address) Means of travel (car, taxi, public transit, etc.) *Please append additional sheet if needed. ~ 7 ~ Nov 2016

KELLY SHIRES BREAST CANCER FOUNDATION. Criteria for Financial Assistance

KELLY SHIRES BREAST CANCER FOUNDATION Criteria for Financial Assistance Title: Criteria for funds administration Revisions: May 1, 2015 Purpose: This criteria guides the association in assessing requests