Download File - Sistahs of Compassion Supporting Cancer

Sistahs of Compassion Supporting Cancer Survivors, Inc.
www.sistahsofcompassion.org
Application for Financial Assistance
PATIENTS INFORMATION (please print clearly)
Today’s date: _______________________________
First name:______________________________ Last name: ___________________________
Address: ___________________________________ City, Zip: _________________________
Phone number: Home (
) ____________________ Cell (
Ethnicity: ____ African American ____White _____Latino

Male

Female
MEDICAL INFORMATION
) _______________________
_____ Asian _____ Other
** THIS SECTION MUST BE COMPLETED BY YOUR ONCOLOGY NURSE, DOCTOR,
SOCIAL WORKER OR HOSPITAL ACS PATIENT NAVIGATOR ONLY***
Date of diagnosis: ____________ Primary cancer: _________________Current stage ________
____ New diagnosis
____Recurrence
Is patient in active treatment? Yes
No
If not in active treatment, indicate frequency of follow-up: ___ Yearly ___ Every six months ____ Other
Please indicate type of treatment(s) received in past twelve (12) months (check all that apply)
____ Chemotherapy ____Radiation ____Surgery ____Hormonal ____Palliative care
____ Bone marrow/stem cell transplant
HEALTH CARE PROFESSIONAL INFORMATION (Please print ):
MD name: ________________________________________ Hospital/Clinic: ____________________________
Address: _________________________________________ City, Zip: __________________________________
Phone: (
) _____________________________________ Fax: (
) __________________________________
NAME AND TITLE OF PERSON COMPLETING THIS SECTION, IF DIFFERENT THAN ABOVE (please print)
Phone: (
)____________________________________ Email: ______________________________________
Your relationship to person applying for help: ___ Doctor ___Nurse _____ Social Worker
____ ACS Hospital Patient Navigator
Signature of MEDICAL Professional: ______________________________________________________________
Incomplete applications are not accepted
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APPLICANT’S NAME: ________________________________
THIS PAGE IS TO BE COMPLETED BY THE PATIENT/PERSON REQUESTING FINANCIAL ASSISTANCE:
HEALTH INSURANCE INFORMATION
Does the patient have health insurance?
____Yes
_____No
If yes, please indicate type of insurance (check all that apply):
____Medicare
____Medicare plus Medigap
Are prescription drugs covered?
_____Yes
____ Private insurance
____ Charity care
____ Medicaid
____VA program
____No
HOUSEHOLD FINANCIAL INFORMATION
Is patient currently employed? _____Yes
_____No
Number of people in household: ______________
FAMILY INCOME SOURCES (please check all that apply):
___Social Security (retirement)
___Salary
___Pension
___Public assistance
___Short-term disability
___Unemployment
___SSD (Disability)
___SSI
____Family/friends provide support
___Other – specify _____________________________
Please be aware that funds are limited and based on availability as well as on meeting SOC’s eligibility
requirements. Our support is NOT for expenses such as ***, ***, *** and we do not provide assistance for
medical bills or insurance co-payments. If you need this type of assistance, please refer to your local ACS agency
for help.
FINANCIAL ASSISTANCE NEEDS (check all that apply):
I need help with the following cancer-related expenses:
Name of person completing this section (please print) ________________________________________________
____ Transportation
____Pain medications
____Lymphedema Supplies (for breast cancer only)
Signature: _____________________________________________ Date: ______________________________
Relationship to person applying for help: _____Self ____Spouse
_____Family member/caregiver
___ Health care professional
***I ATTEST BY WAY OF MY SIGNATURE THAT ANY FINANCIAL ASSISTANCE MAY BE AWARDED
WILL BE UTILIZED FOR THE EXPENSES INDICATED ABOVE***
THANK YOU.
Mail this form to P.O. Box 12253, St. Petersburg, FL 33733.
SOC will review and meet the 3rd Thursday of every month.
We will review this information and contact the person requesting financial assistance no later than the 3 rd
Friday of every month.
All information is strictly confidential and is for Sistahs of Compassion use only.
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Sistahs of Compassion Supporting Cancer Survivors (SOC)
What is Financial Assistance from SOC?
 SOC provides limited financial assistance to help with the costs of treatment-related
transportation, child care, and home care for all types of cancer.
 SOC’s financial assistance does not cover basic living expenses such as rent or
mortgages.
Who is eligible?
In order to be eligible for financial assistance you must:
 Have a diagnosis of cancer as certified by an oncology healthcare provider
 Be in active treatment for your cancer
Meet our financial eligibility guidelines AND provide proof of income.
Acceptable proof of income includes:
 The first two pages of your recently signed copy of income tax return. (Please
blacken out your social security number).
-OR If you do not file a tax return: Copies of your most recent pay stub, unemployment
check or SSI, SSD or public assistance benefit notification
-OR If you do not have income: Provide a letter of support from friend or family member
How do I apply?
These steps MUST BE COMPLETED in order for an application to be considered.
1. You must speak with two (2) SOC Board members to conduct a brief consultation.
Call our office 727-362-8935 or personally via cell phone.
2. If you are eligible for financial assistance, we will provide you with an application.
3. You MUST submit a completed financial assistance application.
 Please PRINT clearly, as illegible application cannot be processed.
 Please fill in each blank space in the application. Use ‘no’, ‘none’, or ‘0’ as appropriate;
do not leave blank response.
 A medical oncology professional must complete all sections of the Medical
Information Section and provide a signature and date. You or your family member
cannot complete this section!
 Note the correct SOC mailing address listed on our application.
PLEASE NOTE: An application is not a guarantee for receiving financial support from SOC. Funds are
limited and based on eligibility and availability. We are unable to process incomplete applications
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GUIDELINES
In order to qualify for “The Jackie Brown” Legacy Award from SOC you must:
1.
Live in the Tampa Bay area
2.
Be a diagnosed cancer patient and in active treatment at the
time of application.
3.
Be recommended to SOC by a member of the family’s oncology team.
This can be a social worker, clinician, or healthcare professional.
4.
Be aware that this is an annual award that is used to pay treatmentrelated transportation, child care, and home care for all types of
cancer. It must be 366 days before patient could request
the SOC award.
5.
Be aware that award money is paid directly to services or
vendors and may not be given directly to requestor.
Sistahs of Compassion Supporting Cancer Survivors Inc., a Florida non-profit 501c3 organization.
Sistahs of Compassion Supporting Cancer Survivors, Inc.*P.O. Box 12253*St. Petersburg, FL 33712*727-362-8935
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