Safety Net Grant Program

Similar documents
Confinement Waiver Instructions

Ellie s Army Foundation Grant Application

Ellie s Army Foundation

Family Assistance Program

Advantage Physical Therapy Patient Registration

PLEASE CHECK ALL BOXES THAT APPLY AND COMPLETE THE APPROPRIATE SECTION(S) OF THE FORM. Patient name: Date of birth: Sex: M F

ADDRESS: APT#: CITY: ZIP: IF ANOTHR PHYSICIAN, WHO?

Billing Address for responsible party (if different from home): Subscriber: DOB: Employer:

Covis Pharmaceuticals, Inc. Patient Assistance Program

FLORIDA TECH EMPLOYEE ACCIDENT/ INJURY REPORT

SUPPLEMENTAL INFORMATION. Spouse Information Form

Lake County Neuromonitoring, LLC Libertyville, Illinois Lake County Imaging, LLC P: Lakeshore Physical Therapy, LLC F:

BILL L. JOU, M.D., INC.

APPLICATION FOR ASSISTANCE

FLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty

MP+ International Claim Form & Authorization Filing Instructions

If it is not, call your insurance company and have them change the Children s Medical Center to one of Children s Medical Center physicians.

Travel Reimbursement Guide

(Please Print using Black or Blue Ink) SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER

If you do not have access to a fax machine, send the completed application and any additional documents to:

HIPAA PRIVACY RULE: WHEN TO OBTAIN AUTHORIZATIONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

APPLICATION FOR ASSISTANCE (CHILDREN)

The Merck Access Program ENROLLMENT FORM

PATIENT INFORMATION PATIENT INFORMATION. Middle Initial: Nickname: Date of Birth: Marital Status: Address: City: State: Zip Code:

CANCER CLAIM FORM INSTRUCTIONS. To avoid delays in processing of your claim form, complete each section attaching documentation below when it applies.

TULANE UNIVERSITY ATHLETICS CAMPS Physical Examination Information. Date / / Name of Camp: Name of Participant: Age: Birth date: / /

GREENWOOD DERMATOLOGY

PROCEDURES FOR SCHOOL DISTRICT 11 APPROVED FIELD TRIPS

Please indicate the following:

Agent Mailing Address City State Zip Code. Agent Address

Long Pond Pediatrics & Osteopathy Dr. Sabine M. Schmitt, DO, FAAP, C.S.P.O.M.M. Dr. Shoshana Katz, MD, FAAP Dr. Kimberly Ingalls, MD, FAAP, M.P.

Legal first and last name of person being assessed today: Marital Status: Social Security #: State: Zip: Employer:

New Patient Intake Form Pregnancy Specific

Braeburn Patient Assistance Program Application

Lifetime Limits Effective September 23, 2010, payors are prohibited from placing lifetime dollar limits on medical claims.

APPLICATION FOR ASSISTANCE (ADULTS)

Baldwin Counseling Payment Agreement

Consent for Purposes of Treatment, Payment and Healthcare Operations

PATIENT APPLICATION FORM

Aon s Student Accident Protection Plan School student accident claim form

Missouri Individual and Family Plan Enrollment Application / Change Form

Cystic Fibrosis Foundation Compass Request Form Please use this form to request assistance from the CF Foundation Compass

Step 2: Request an invoice number for every trip for your records and proof of approval.

MasterCare Physical Therapy, Inc.

PART A HOSPITAL SERVICES PER BENEFIT PERIOD SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION*

PLEASE CHECK ALL BOXES THAT APPLY AND COMPLETE THE APPROPRIATE SECTION(S) OF THE FORM

PHARMACY INFORMATION

BACK-HEALTH CHIROPRACTIC INITIAL PATIENT REGISTRATION (2016) Dr. Goudarz Vassigh, DC THIS SECTION REFERS TO PATIENT ONLY

All About Kids Pediatric Dentistry

Parkway Dental of Clinton Matthew K. Chow, D.D.S. 401 Clinton Parkway, Clinton, MS Patient Information:

PATIENT INFORMATION DEMOGRAPHICS. First Name Middle Initial Last Name Gender. Mailing address: Apt # City: State: ZIP Code: Home Phone Cell Phone

Signing up for a Health Savings Account (HSA) puts more money in your pocket.

KATINE & NECHMAN L.L.P.

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:

To avoid delays in processing of your claim form, complete each section attaching documentation below when it applies.

Medicare Educational Video. Presented by: Medicare Simplified Medicare Simplified. All rights reserved.

MBA Opens Doors Foundation SM Mortgage Assistance Grant Application

OFFICE OF INSURANCE REGULATION Life & Health Product Review INDIVIDUAL HEALTH CONTRACT CHECKLIST

Prior Authorization, Pharmacy and Health Case Management Information. Prior Authorization. Pharmacy Information. Health Case Management

Basics of Health Insurance. Copyright 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

NeedyMeds

VISITORS TO CANADA Insurance Claim Form

Drug Prior Authorization Form

Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need.

APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE INDIANA

PRO SPORTS THERAPY, INC. (P.S.T.)

M F Last Name First Name Middle Initial Gender. Home Phone: Work Phone: Cell Phone: Physical Address: Mailing Address (if different):

Humana Insurance Company Hospital Indemnity Claim Filing Instructions

PLEASE CHECK ALL BOXES THAT APPLY AND COMPLETE THE APPROPRIATE SECTION(S) OF THE FORM. Patient name: _Date of birth: Sex: M F

Authorization to Release Health Information

Blue Select Policy Comparison Chart Effective January 1, 2018 Blue Select Part A Hospital Insurance Covered Services

NATIONAL SLOVAK SOCIETY OF THE UNITED STATES OF AMERICA

Issuance of this form does not amount to admission of any liability of under the policy on the part of the insurers

Medical claim form. Your personal data. City ZIP code. Your medical treatment Type of illness or accident

PHYSICAL THERAPY & CHIROPRACTIC CARE

The Empire Plan is a comprehensive health insurance program, consisting of four main parts:

Prior Authorization, Pharmacy and Health Case Management Information. Prior Authorization. Pharmacy Information. Health Case Management

Lions Eye Foundation of California-Nevada, Inc.

PATIENT REGISTRATION

Medical Emergency and Associated Expenses

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:

Prior Authorization, Pharmacy and Health Case Management Information. Prior Authorization. Pharmacy Information. Health Case Management

STUDENT APPLICATION, CONSENT, MEDICAL AUTHORIZATION, AND RELEASE AGREEMENT (International Travel)

FHA-Lender ENGAGEMENT LETTER

RULES OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION DIVISION OF TENNCARE CHAPTER COVERKIDS TABLE OF CONTENTS

Insurance Claim Filing Instructions

Elevator Constructors Union Local No. 1 Annuity & 401(k) Fund 140 Sylvan Avenue, Suite 303, Englewood Cliffs, NJ (201) (855)

WOMEN S PREMIER OBGYN REGISTRATION FORM

Drug Prior Authorization Form

Provider Training Tool & Quick Reference Guide

Basic, including 100% Part B coinsurance. Foreign Travel Emergency

Medical Emergency and Associated Expenses

BlueCare Policy Comparison Chart Effective January 1, 2019 BlueCare Part A Hospital Insurance Covered Services

Guidelines for Financial Assistance

NeedyMeds

Child Resident Street Address (required - a PO Box will not be accepted) City County State Zip. Mailing address (if different) City County State Zip

THE CLAIMS PROCESS. Your guide to the claims experience

AMENDMENT TO THE DEPOSIT ACCOUNT AGREEMENT

Preauthorization Form Request For Cashless Hospitalisation For Medical Insurance Policy

PATIENT INFORMATION. Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex:

Transcription:

Safety Net Grant Program Description: The National Pediatric Cancer Foundation s Safety Net Grant Program assists cancer patients (children under the age of 18) with advanced cancer treatment related costs. This is an on-line grant program for reimbursable event related support meaning, the grant does not support unpaid expenses, only expenses validated with a current / original invoice & payment receipt for said expense. Receipts are required to be submitted with the grant application. Support is restricted to the following reasons: 1. Durable home based medical supplies/equipment/mobility aids 2. Medication - prescription and over-the-counter 3. Transportation costs to and/or from treatment 4. Insurance co-payments & out-of-pocket plan deductibles Eligibility: Patient must be currently undergoing treatment in relation to a cancer related clinical trial or advanced form of cancer therapy treatment Patient must be a legal citizen of the USA and be under the age of 18 as of the day of treatment Patient s treatment must be validated (signature on application) by a licensed healthcare provider providing said treatment and by supporting parent/legal guardian Financial assistance by the NPCF is considered "last resort" funding Applicants must demonstrate financial need on the patient application. Financial needs will be assessed based on numerous factors including household income, and size as compared to the cost of basic needs by county. Patients must be alive at the time that the grant is issued. Financial assistance related to postmortem expenses or expenditures incurred after death will not be considered for reimbursement Applicants may apply at six-month intervals limited to two per calendar year. The maximum grant amount per application is $500.00 Number of annual grants current program awards one $500 grant per six month period

Application Requirements: 1. Application is complete and signed by both the patient s guardian and the Recommending healthcare provider. 2. In the case of attached receipts and support documentation, we should receive the following: a. Transportation: Attach a description of required travel for treatment including treatment dates, to/from destination and either gas receipts for respective dates or mileage amounts for each specific reimbursement date being requested. If mileage is requested, we will reimburse at a rate of $.19 per mile which is the approved IRS rate for medical mileage. We will either reimburse for mileage or gas receipts but not a combination of the two. b. Medical Supplies: Include description of supplies or equipment being requested and corresponding receipt evidencing payment of equipment. c. Medication: Include corresponding receipts for prescribed medication or over the counter medication needed. We will reimburse any out of pocket costs not covered by insurance. d. Insurance Co Payment and Deductibles: Attach receipts for payment of any copayment and/ or deductibles either for doctor visits, hospital stays, or medical care incurred for patient. 3. All receipts should fall within the treatment dates shown in the application. 4. Household Income Information Attach latest Income Tax return for said household. Process: 1. To apply for support, mail the application below to: NPCF, Attn: Safety Net @ 5550 West Executive Drive., suite 300, Tampa, FL 33609 or email: safetynet@nationalpcf.org 2. In some situations, NPCF may choose to institute a grant cap &/or close or suspend the program. Information will be posted on the NPCF website. NPCF also reserves the right to institute changes to grant maximums. 3. The decision to provide assistance in response to any given application or request is at all times subject to the sole and absolute discretion of NPCF. The NPCF Safety Net Program is not an entitlement program. There is no right to a grant or financial assistance, either initially or for any given period. NPCF reserves the right to modify or withdraw at any time any commitment as to any grant or financial assistance. Without limiting the foregoing, a finding of eligibility does not give rise to entitlement to financial assistance which, upon other variables, depends on available funds in the SNP pool. NPCF reserves the right, exercisable in its sole and absolute discretion, to revise eligibility criteria, from time to time, and make such changes effective as of any date selected by NPCF. In addition, and without limiting the discretion of NPCF as set forth above, applicants are advised that false or deceptive representations in connection with

eligibility for participation in the program, fraudulent conduct, or gross misconduct shall result in the immediate disqualification of an application for a grant, eligibility for future grant, &/or the termination and cancelation of a grant which has been approved. NPCF also reserves the right to obtain any applicable refund for cancelled grants. 4. NPCF reserves the right to request additional backup documentation to validate application information. 5. NPCF reserves the right to require new annual applications for all enrollees to ensure system accuracy and applicant eligibility. 6. All applications must be signed by the patient, parent or legal guardian on whose behalf SNP assistance is requested, and validated (signed) by a licensed healthcare provider. If the patient is unable to sign the Consent Form, it is permissible for a legally authorized representative of the patient (e.g., a person who has a power-of-attorney) to sign on behalf of the patient). The signed Consent Form cannot be older than 60 days of the application submission date. 7. Please allow NPCF at least 2 weeks to process and mail premium payments. Most requests, if correctly submitted, are processed within 10-14 days. 8. You may contact NPCF at 1-813-269-0955

SAFETY NET PROGRAM - APPLICATION: Patient Name: Patient s Birth Date: Patient s parent &/or legal guardian: Patient s parent &/or legal guardian agreement with program eligibility: Yes / No Home address: Phone: Parent / Guardian Email: Date of application VALIDATION / REQUEST FOR SUPPORT I request the following assistance and thereby submit validation / description of paid expenses: (check appropriate boxes and describe documents attached with this application) Transportation: Medicalsupplies: Medication: Co- Payment and /or deductible payments:

HOUSEHOLD FINANCIAL INFORMATION: Number of People in Household: Number of People Employed in Household: Total Annual Household Income: (include all sources of income): (attach last calendar year s tax return) RECOMMENDING HEALTHCARE PROVIDER INFORMATION: Name/title/Provider: Healthcare Provider Relationship to Patient: (Physician, Nurse, Social Worker) Diagnosis Information and Date: Treatment dates: (from / to): Type of Treatment Received in the Past 12 Months: Provider email & phone # Recommending (healthcare provider s) signature: Requested amount (validated with attached receipts): Signature of Healthcare Provider Date PATIENT / GUARDIAN VERIFICATION I understand that by signing this application, I agree the above information is truthful and accurate to the best of my ability. I qualify for assistance based on eligibility requirements noted above. NPCF may need to contact me to verify the above information. Funding for this program is subject to availability of funds and approval of this grant is at the sole discretion of NPCF. All information provided will be kept confidential. No information will be made available or sold to a third party and is the sole property of NPCF. Signature of Applicant (Parent/legal guardian) Date NPCF Internal:

2024 © financedocbox.com Privacy Policy | Terms of Service | Feedback