2020 Financial Assistance Program Application

Dear Applicant, Thank you for your interest in The Cancer Foundation’s (TCF) Financial Assistance Program. TCF is a non-profit organization whose mission is to help alleviate the financial burden of cancer for eligible patients.

Enclosed is The Cancer Foundation’s application for financial assistance. Please note that applications must be submitted to The Foundation by a referring professional (i.e. your doctor, a nurse, social worker, patient navigator, or other health care professional who is involved with your care). Please read the instructions carefully and fill out the application completely. Also, be certain to list all current expenses and complete income information. TCF uses this information to gain a complete understanding of your current financial situation. Be sure to attach copies of the bill(s) that you would like the foundation to consider for payment as well as proof of income documents.

Referring professionals are asked to mail a completed application to the following address or email address: The Cancer Foundation P.O. Box 49309 Athens, GA 30604-9309 OR email kmoody@cfnega.org Thank you again for your interest in The Cancer Foundation. Should you have any questions about this application, please call (706) 308-1355 or via e-mail at kmoody@cfnega.org.

Sincerely,

Katrina Moody The Cancer Foundation Program Manager

The Cancer Foundation Financial Assistance Program (“FAP") Applicants must meet the following eligibility criteria to be considered for the FAP. □ Reside in the TCF service area which includes: Banks, Barrow, Clarke, Elbert, Franklin, Greene, Habersham, Hart, Jackson, Jasper, Lumpkin, Madison, Morgan, Newton, Oconee, Oglethorpe, Putnam, Rabun, Stephens, Taliaferro, Towns, Union, Walton, White, and Wilkes Counties. □ Must be at least 18 years old. □ Have a cancer diagnosis as certified by healthcare provider and a) be in active treatment, or b) on hospice related to a cancer diagnosis. Active treatment includes chemotherapy, radiation therapy, hormone therapy, immunotherapy, or cancer related surgery. Patients are eligible to apply during treatment or within a six-month period following their last cancer treatment. □ Have household* income less than or equal to 250% of the 2020 Federal Poverty Limits. □ Must be able to provide proof of income for each person in household over 18 years.

Household Size 1 2 3 4 5

Gross Monthly Income $2,658 $3,592 $4,525 $5,458 $6,392

Gross Annual Income $31,900 $43,100 $54,300 $65,500 $76,700

*From US Department of Health and Human Services *Household is defined as any persons residing together related by blood, marriage, commitment, or legal adoption that are dependent on the combined income.

*Please note, income limits are based off household’s Gross income, which is the income before deductions.* Required income documentation: ▪ If making wages, must provide paystubs from the last two months or a statement from employer.

▪ If receiving income other than wages, please provide one of the following: o Bank statements from the last two months o Social Security benefit letter o Social Security 1099 o Copy of Social Security check ▪ If a patient is receiving no income, please provide a letter stating the reason for no income.

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Report resources/assets** totaling less than: • $9,000 (single individual) • $12,000 (couple) • $15,000 (family)

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List other agencies or sources from which you have requested funding if any.

**Resources/Assets include: 1. Checking Accounts and/or cash 2. Savings/Money Market Accounts 3. Stocks/Bonds 4. CDs 5. Mutual Funds/Taxable Annuities ** Resources do not include: 1. Equity in Primary residence 2. Value of automobiles 3. Retirement Accounts (Restricted) 4. Educational Accounts (Restricted) 5. Personal Possessions

FAP Guidelines: ▪ Financial assistance will be awarded to assist with the following expenses (as applicable): • Housing: rent/mortgage payments/security deposits/home insurance/property taxes • Utilities: gas, electric, water, propane, internet, and phone (no cable, satellite or TV streaming) • Health Insurance Premiums (COBRA included) • Medical office visit or service co-payment • Nutritional supplements such as Boost, Ensure, Jevity, etc.

• Durable and consumable medical equipment or supplies prescribed/recommended by physician (i.e.: lymphedema supplies, walkers, wheelchairs, bedside toilets, etc…)

• Medication costs—patient portion • Transportation in the form of gas cards/Uber gift cards; medical transport, bus passes *Patients may use all of their assistance in the form of gas cards which come in increments of $250. Only one gas card will be sent at a time. A second and third gas card may be requested with at least 30 days between requests.

• Dental work required by the patient’s oncologist considered to be a barrier to treatment • Funeral Costs (for the patient only where an approved application was submitted during treatment or hospice and is within the 6 month approved window; this expense is intended to allow the family to utilize an existing balance with TCF.) ▪

Payments will be made directly to company/creditor that is owed. Applicants must supply copies of the bill, late notice, mortgage statement, lease agreement and payment address and phone number.

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Applicants may request up to $750.00 per year.

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Applicants may reapply for financial assistance on the first business day of the following calendar year as long as they remain eligible.

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Applicants must be referred by a physician, physician assistant, nurse, social worker, patient account representative, patient navigator or financial counselor.

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The Cancer Foundation collects data for research and statistical purposes. Applicants may decline to take part in this process. Participation in data tracking is not required and will not be considered in awarding financial assistance.

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No identifying patient information that is provided voluntarily on the required application will be used by The Cancer Foundation for any purpose other than to approve assistance requests.

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Only completed applications will be considered; a complete application includes the application form, supporting proof of income documentation, the referring professional payment request form and copies/scans of all necessary patient bills to be paid.

The Cancer Foundation Financial Assistance Program Application All requests for funding must be presented in writing using this form.

Please include any other supporting documents.

Date of Application: ____________

Applicant’s name: __________________________________

Last Four Digits of Social Security #_______ (not required) Check one of the following: □ Single

□ Married

D.O.B.__________________

□ Divorced

□ Widowed

□ Separated

Number of person(s) dependent on income: ____ Number of person(s) under 18 dependent on income:____ Ethnicity: □ Asian

□ African American

□ Hispanic

□ Native American

□ White

□ Other

Address: _________________________________________________________________________________ City/State/Zip: ______________________________

County: ___________

Phone Number: ______________________________

Email: _____________________________________

Emergency Contact: ___________________________

Phone Number: _____________________________

What type of cancer do you have? _________________________________ Are you currently receiving treatment? _____

Date of Diagnosis: ________

Who is your oncologist? _____________________________

Where are you receiving treatment?_______________________________________________________ Who is your referring professional?________________________________________________________ If you are not currently in treatment when was your last treatment? ____________________________ Amount Requested: _________________ Have you ever received financial assistance from The Cancer Foundation before? □ Yes □ No What do you need assistance with? ____________________________________________________________ _________________________________________________________________________________________ We would like you to rate your financial stress using what’s called a “stress scale” which is similar to the pain scale used at the hospital to rate your pain. The stress scale goes from 1 to 10, with 1 meaning you feel no stress and 10 meaning you feel the highest level of stress. When you consider your overall financial situation today, how stressed are you now on a scale of 1-10? ____ List other agencies you have contacted for help and when: ________________________________________________________ __________________________________________________________________________________________________________________________

Complete the following chart with the patient’s income, expenses, and resources.

Monthly Household Gross Income Cash $ Wages (pre$ deductions) Social Security $ Disability $ Unemployment $ Retirement/Pe $ nsion Other Total

$ $

Monthly Household Expenses Rent/Mortgage $ Utilities $ Groceries/Food Transportation Car Payment Out of Pocket Medical Expenses Other Expenses Total

$ $ $ $

$ $

Household Resources Checking Savings

$ $

Money Market Stocks/Bonds C.D’S Mutual Funds/ Taxable Annuities Other Total

$ $ $ $

$ $

I choose to participate in TCF’s efforts to track applicant information for research and statistical purposes. I understand that receiving financial assistance from TCF is not contingent on providing this information. □ Yes □ No All information I have provided is true and correct. I understand that any financial assistance provided by the Foundation is provided directly to my creditors, is limited, and is based on the immediate needs that negatively impact my health status. I understand this application will expire six months from date of the submission. Providing false information will result in denial of assistance.

I authorize the Foundation to contact my health care provider(s) listed above, and I authorize my health care provider(s) to release information to the Foundation related to this application. If requested by my health care provider(s), I will complete an appropriate authorization to allow him/her to release information to the Foundation pertaining to this application. All information provided to the Foundation will remain confidential, except that the Foundation may disclose information to my creditors and others as may be necessary to provide financial assistance.

I understand that although the Foundation may consider billing cycles and due dates when providing financial assistance, I remain fully responsible for timely payments of my debts, and I will indemnify and hold harmless the Foundation for any expenses, losses, or liabilities arising from or related to my debts. ___________________________________________ Applicant’s Signature

______________ Date

Referring Professional Payment Request Form

Date of Request:______

To be completed by referring professional; this form accompanies the application form.

Patient Name:

DOB:

__

Please pick the category that best describes how this request benefits the individual? Check all that apply to the bills submitted today.

Prescriptions not covered by insurance

Medical office visit or service co-payments (no coinsurance or deductibles)

Funeral Costs (if patient has active application and balance to utilize)

Nutritional Supplements: (Ensure/Boost/Jevity, etc.)

Utility bills for gas, electric, water, propane, internet, and phone (No Cable)

Type of Supplement:____________

Durable Medical Equipment/Consumable Medical Supplies

What flavor? _____________

Health Insurance premiums [COBRA]premiums included Rent/Mortgage payments/Security deposits/ Home Insurance/Property Taxes

How many cases? __________ Transportation costs: $250 Shell gas card (only one per 30 days) ____________________ $100 Uber cards ______________________ Medical Transport ____________________ Bus Pass/Lift ___________________________

Bill Name, Address, Phone (required)

Account #

Amount Requested $ $ $ $ $

Total request (max $750) :

$

Attach bills to support each request except if requesting a gas card.

Please provide any additional information that may assist TCF in making payment arrangements: ___ ______________________________ I reviewed this application and I agree with the funding need.

Referring professional -Print Name & Date Referring professional -Signature Organization: _____________________________ Phone: Fax: Has your patient’s household income been impacted by COVID-19? [ ] Yes [ ] No Please email this form to Katrina Moody at kmoody@cfnega.org. We do not accept faxed applications.