Application for Financial Assistance

Personal Information

Name:(Required)

First Last

Date of Birth:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP

County:(Required)

THE BCFCF CLIENT ASSISTANCE PROGRAM PROVIDES ASSISTANCE TO RESIDENTS RECEIVING TREATMENTS IN POLK, PINELLAS, OR HILLSBOROUGH COUNTY, FLORIDA, ONLY. IF YOU RESIDE IN ANY OTHER STATE, PLEASE STOP HERE.

Email:(Required)

Phone:(Required)

Marital Status:(Required)

# Wage Earners in Household (over 18):(Required)

Total # of People Living in Household:(Required)

Number of Dependents in Household:(Required)

Ages of Dependents in Household:(Required)

Please separate with a comma

Tell Us Your Story

Write your story below and how a BCFCF Client Assistance award would make a difference to you and your family during this time. Please include any information about your current or expected financial situation that you would like us to know or that you think would help us make a decision, such as a financial hardship, excessive medical expenses, seasonal or temporary income, personal loss, or any other special circumstance that may be impacting you.If you have additional information or documents you’d like to share with our Board as they consider your application for approval, please upload them in the “Additional Documents” section below.

My Story:(Required)

Additional Documents:

Drop files here or

Max. file size: 64 MB.

Medical Information

Referred By:(Required)

Date Diagnosed:(Required)

Type of Cancer:(Required)

Stage/Grade:(Required)

Chemotherapy

Start Date:

End Date:

Radiation

Start Date:

End Date:

Other Therapy or Treatment Details (Please attach Specialist notes, Pathology reports, Imaging Studies, if applicable.):

Attach Documents (if applicable):

Drop files here or

Max. file size: 64 MB.

Oncologist, Patient Advocate, or Nurse Navigator Name:(Required)

Phone:(Required)

Hospital or Oncology Office:(Required)

Additional Medical Contacts

Please provide the name, email address, and phone number for the following providers with whom we may discuss your application if we can't reach you or require additional information (please complete the HIPAA release form near the end of this form.

Surgeon

Name:(Required)

Primary Contact(Required)

Phone(Required)

Email(Required)

Oncologist

Name:(Required)

Primary Contact(Required)

Phone(Required)

Email(Required)

Oncology Nurse

Name:(Required)

Primary Contact(Required)

Phone(Required)

Email(Required)

Other Contacts

Name

Phone

Email

Please read these items carefully and check the true boxes:

I understand the BCFCF Client Assistance Program DOES NOT pay for medical expenses of any kind.

I am currently a patient either recovering from a cancer-related surgery, and/or I am currently undergoing chemotherapy or radiation.

I hereby grant the BCFCF Client Assistance Program full authorization and permission to obtain the necessary medical information to process my application.

I understand that the BCFCF Client Assistance Program may ask personal questions about my treatment and financial status. I agree to provide accurate answers.

I am not currently receiving any additional financial assistance that I have not already disclosed from any other local or national organization.

Any false or misleading information may result in the termination of the application.

Applicant's Signature:(Required)

By signing above, I certify that all information I have provided to is true and complete to the best of my knowledge.

*** You must also complete all other sections of this application to be considered, including the Financial Disclosure Form and the HIPAA Authorization Form, and provide all documents requested.

Please upload a copy of your driver's license or state-issued ID:(Required)

Drop files here or

Max. file size: 64 MB.

Financial Disclosure Form (To Include Out-of-State, e.g., Snowbirds & Spousal)

Salaries

Self

Partner

Total (Partner & Self)

Social Security Disability and/or State Disability

Self

Partner

Total (Partner & Self)

Workers' Compensation

Self

Partner

Total (Partner & Self)

Pension and/or Annuity Payments

Self

Partner

Total (Partner & Self)

Alimony

Self

Partner

Total (Partner & Self)

Child Support

Self

Partner

Total (Partner & Self)

Interest/Dividends from assets/gross rent from rental properties

Self

Partner

Total (Partner & Self)

Disability Policy benefits or sick pay from the Employer

Self

Partner

Total (Partner & Self)

Total Monthly Income:

Self

Partner

Total (Partner & Self)

Expenses

Enter the monthly amount for each applicable item below.

Mortgage/Rent:

Home Insurance:

(if not already included in mortgage/escrow)

Do you own a 2nd home?

Yes

No

Car Payment(s):

Car Insurance:

Health Insurance:

Groceries:

Electric:

Cell Phone:

Water/Sewer:

Home Phone:

Gas:

Child Support Payments:

Trash:

Monthly Medical Expenses:

Use total

Other:

Description

Monthly Amount

Request for Funding Information

Please rank which expenses you’d like the BCFCF Client Assistance Program to consider paying that would provide the most financial relief. Please rank your priorities using numbers, with 1 as the most helpful. Please note that the BCFCF Fund DOES NOT pay any credit card accounts, home or cell phone bills, or medical-related bills.

Are any of your expenses currently past due?

Yes

No

List Your Financial Priorities

Priority/Rank

Bill Type

Paid To

HIPAA Privacy Authorization Form

Please fill in the fields to provide consent as shown below.

Your Name(Required)

Your Treating Physician(Required)

Start Date(Required)

End Date(Required)

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, “HIPAA”).

1. AUTHORIZATION
I, (YOUR NAME), authorize (YOUR TREATING PHYSICIAN) to disclose the protected health information described below to the BCFCF Client Assistance Program.

2. EFFECTIVE PERIOD
This authorization for release of information covers the period of healthcare from (START DATE) to and through (END DATE).

3. EXTENT OF AUTHORIZATION
I authorize the release of my health record only as it pertains to my cancer diagnosis and treatment.

4. This medical information may be used by the BCFCF Client Assistance Program for the purpose of evaluating my eligibility for financial aid according to their guidelines or for other purposes as I may direct.

5. This authorization shall be in force and effect until (END DATE), at which time this authorization expires.

6. 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.

7. 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.

Applicant Release Form

Your Name(Required)

Today's Date:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP

1. I, (YOUR NAME), hereby grant the BCFCF Client Assistance Program, its agents, community and business partners, subsidiaries and affiliates, and their respective licensees, successors and assigns 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 BCFCF Client Assistance Program and the grant/contribution that I received for commercial or non-commercial purposes, including advertising, public relations, promotion of the BCFCF Client Assistance Program and its products and services, and its partners or affiliates. This will extend to any medium or format whatsoever, including, without limitation, in and on magazines, brochures, and other print publications; press releases; electronic media; and the internet (including the website and social media sites of the BCFCF Client Assistance Program).

2. I further agree and do hereby release and hold harmless the BCFCF Client Assistance Program from any claims, actions, suits, liabilities, or damages arising from use of the Content and weather resulting from the negligence of the BCFCF Client Assistance Program or any other person. I waive any right I may have to make or bring any claim against the BCFCF Client Assistance Program 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 BCFCF Client Assistance Program or authorizing its use in the manner detailed herein.

3. Distribution of funds to any application is at the sole discretion of the BCFCF Client Assistance Program and its Board of Directors.

I HAVE CAREFULLY READ, CLEARLY UNDERSTAND, AND VOLUNTARILY ACKNOWLEDGE THE INFORMATION OUTLINED IN THIS RELEASE FORM. I UNDERSTAND THAT THIS FORM PROVIDES THE BCFCF CLIENT ASSISTANCE PROGRAM WITH MY ABSOLUTE AND UNCONDITIONAL CONSENT, WAIVER, AND RELEASE OF LIABILITY, ALLOWING THE BCFCF CLIENT ASSISTANCE PROGRAM 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.

Please send this COMPLETED APPLICATION (all pages), plus (1) a copy of your driver’s license or state ID, (2) any supplemental information requested, (3) or any additional info that the applicant would like the BCFCF Client Assistance Program to consider as part of their request by email to: clientassistance@bcfcf.org

The BCFCF Client Assistance Program will review all applications and be in touch if additional information is required for review and approval. An Application for Financial Assistance will not be considered unless it is complete. Applications are reviewed monthly, and you will be notified of your final application status usually within thirty (30) days of receipt.

Personal Information

Employment Information

Employer Information

Health Insurance Information

Tell Us Your Story

Medical Information

Additional Medical Contacts

Surgeon

Oncologist

Oncology Nurse

Financial Disclosure Form (To Include Out-of-State, e.g., Snowbirds & Spousal)

Expenses

Request for Funding Information

HIPAA Privacy Authorization Form

Applicant Release Form