Guidelines for Financial Assistance
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- Frank Ross
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1 Guidelines for Financial Assistance 1. Financial assistance provided by National Cancer Assistance Foundation, Inc. (NCAF) is made possible because of generous donors. It is important that these funds be available for families experiencing the greatest financial need. To apply for financial assistance, please complete the attached application. NCAF staff will contact you after your application is received. 2. Individuals must be citizens or lawful, permanent residents of the U.S. who have maintained an uninterrupted residency for 12 months without prior history of the current illness. Noncitizen residents, applying for assistance, must have and provide NCAF with a photocopy (front and back) of their I551 card (green card). 3. If a family possesses liquid assets in excess of $5,000, NCAF reserves the right to request a partial or complete spend-down prior to the approval of financial assistance. 4. All sections of the application must be completed thoroughly and accurately in order for the organization to review the request. Failure to provide complete and truthful information is a basis for denial. 5. In order to review the request for financial assistance, a hospital professional (doctor, nurse or social worker) must send a letter of support along with the application for assistance should include the following: - Individual s full name, date of birth, and diagnosis - Past treatment information - Treatment plan for the next 60 days - Other community resources being utilized 6. Assistance may be requested for up to two months or 60 calendar days. At the end of this time if additional assistance is needed, consideration will be given to those requests submitted in writing by a hospital professional. A new application is only necessary when the length of time between requests exceeds one year. 7. Financial assistance is not retroactive. Requests cannot be processed until all information is received. Financial assistance is not guaranteed and subject to availability of funds. 8. NCAF provides financial assistance for the non-medical costs of getting a patient to treatment and other expenses that may be incurred. 9. NCAF staff will contact you to determine how the organization can best help you with these expenses. NCAF Financial Request 10_2015 Page 1 of 7
2 10. NCAF does not provide financial assistance with expenses outside of the U.S. and/or its territories. 11. NCAF is a charitable organization dependent upon the public for support. NCAF tries to maximize the limited resources available. These guidelines are a statement of NCAF s general policy, and NCAF reserves the right, in its sole discretion, to modify the same at any time without notice. 12. You will not be discriminated against or denied aid because of your race, religion, color, national origin, sex or political affiliation. 13. All financial applications will be reviewed on a case by case basis and final determination will be made based upon other applications submitted and the availability of funds. 14. The information you provide to us will be held in confidence and used only in appropriate ways consistent with the reasons for which it was provided. The completed application should be: ed to requests@natcaf.org or faxed to NCAF Financial Request 10_2015 Page 2 of 7
3 National Cancer Assistance Foundation, Inc. Request for Financial Assistance Program applied to: Breast Cancer Assistance Fund Children s Cancer Assistance Fund Children s Cancer Dream Network Family Cancer Assistance Fund Date of Application: Patient Name (first, middle, last) Male Female Date of Birth Place of Birth (State/Country) SS# Patient s Address Marital status: Single Married Divorced Cohabitants Spouses Name Home Phone # Cell Phone # Is address same as patient s? Yes No If no, address Does Patient speak English? Yes No If no, primary language? How did you hear about National Cancer Assistance Foundation, Inc? Emergency Contact Name (other than spouse listed above) Relationship Phone Employment Patient Net Annual Employer Salary Phone # Is Patient on unpaid leave? Yes No Spouse Net Annual Employer Salary Phone # Is Spouse on unpaid leave? Yes No Other Income: SSI Other NCAF Financial Request 10_2015 Page 3 of 7
4 Patient Name Banking and Investments (Please include banking information for all accounts.) *To expedite processing your application, please include a copy of your most recent statements for all of the accounts below. If a family possesses liquid assets in excess of $5,000, NCAF reserves the right to request a partial or complete spend-down prior to the approval of financial assistance. Name of Bank Name of Bank (Please include information for money markets, CDs, mutual funds, stocks, and other investments. Do not include IRA s or other retirement accounts.) Type of Account Type of Account Amount Amount Fundraising Has money been raised on behalf of the applicant? Yes No How much is currently in the account? If yes, please state restrictions: If yes, how much? Are there any restrictions on the account? Yes No Name of Bank Account # Assistance from Other Organizations If you have applied for or received assistance from another organization, please list. Organization Type of Assistance Organization Organization Type of Assistance Type of Assistance NCAF Financial Request 10_2015 Page 4 of 7
5 Patient Name A letter from social worker, nurse or doctor explaining the patient s diagnosis, family situation, and the assistance being requested is needed in addition to the completion of this section. See guidelines for necessary information. Name of Hospital Patient Information # Social Worker (first and last name) Phone # Pager # Mailing Address Dept. Name of Physician (first and last name) Phone # Diagnosis Date of diagnosis Number of relapses Date of relapse Other treatment facility involved in patient s care Social Worker (first and last name) Phone # Pager # Mailing Address Dept. NCAF Financial Request 10_2015 Page 5 of 7
6 Patient Name I do hereby authorize all hospitals, financial institutions, and insurance groups to release to National Cancer Assistance Foundation, Inc., or its duly authorized representative, any information deemed necessary to complete its investigation of my application for financial assistance. I further authorize NCAF and its representatives to provide such information to those institutions as may be reasonably required to assist our family and our child. All consents given herein shall continue until such time as the undersigned provides notice of termination in writing. As an inducement to National Cancer Assistance Foundation, Inc., a non-profit organization, to advance supplemental financial support in conjunction with the medical treatment of (patient), the undersigned to hereby affirm as follows: 1. The term non-medical expenses is understood to mean those reasonable and necessary expenses incurred by the family of the above-named patient or the above named patient, in conjunction with that patient receiving medical treatment. Financial assistance will be provided, with the use of said funds to be specified by NCAF. 2. The undersigned further agree(s) to return any unused funds immediately to National Cancer Assistance Foundation, Inc. so that those funds can be utilized by the organization to benefit other families. 3. The undersigned acknowledges(s) and agree(s) to maintain records that will be made available to National Cancer Assistance Foundation, Inc. upon reasonable request, detailing the expenditures made from the funds provided by the organization. National Cancer Assistance Foundation, Inc. will pursue restitution for grants if it is determined that the information submitted on the application is false. I have read the guidelines for financial assistance and I declare that the information furnished on this application form, including attached sheets, is true and correct to the best of my knowledge. Dated this _ day of, in the year. Patient Signature SSN: Please Print Name Signature : (parent/guardian signature required for minors) Date : Witness: NCAF Financial Request 10_2015 Page 6 of 7
7 Consent Form Please print clearly I hereby give my permission for National Cancer Assistance Foundation, Inc. (NCAF) and/or its representatives to use artwork, photographs and/or letters that I provide of my family or myself in publications, slides, videotapes, motion pictures or on the internet. In addition, I hereby give my permission for National Cancer Assistance Foundation, Inc. and/or its representatives to photograph, audio tape record, or videotape my family or myself and to use our names, these images or voice recordings in publications, slides, videotapes, motion pictures or on the internet. I understand these visual images or voice recordings may be used to inform families, volunteers, donors, the media and general public about NCAF programs, services or events. I gladly give this authorization to support the efforts of National Cancer Assistance Foundation, Inc. I understand this authorization shall continue until terminated in writing. Signing the consent form is not a requirement in order to receive assistance from National Cancer Assistance Foundation. Signature : Date : Parent/guardian Signature : (parent/guardian signature required for minors) Date : Please complete one form per participant/volunteer. NCAF Financial Request 10_2015 Page 7 of 7
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