Application for Assistance – Idaho Pediatric Cancer Coalition

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Application for Assitance

MISSION:
The mission of IPCC is to provide structured services to mitigate the emotional, financial, and physical stress associated with a child being diagnosed with cancer by personifying the love and support available throughout Idaho immediately following diagnosis and throughout the duration of treatment.

INSTRUCTIONS FOR FINANCIAL ASSISTANCE:

Please complete the attached application and return it to Idaho Pediatric Cancer Coalition office by email or mail; the addresses are listed above. You will be contacted by a staff member when it has been received.

Patient Information

First Name *

Last Name *

Gender

Birthdate

Age At Diagnosis *

Patient’s Interests & Hobbies *

Guardian Information

Parent/Guardian Name(s) *

Marital Status of Parents/Guardians

If divorced, please provide name of custodial parent

Street Address *

Apartment, suite, etc

City *

State *

ZIP

Home Phone

Cell Phone

Email Address

Places of employment of Parents/Guardians

Household Information

Primary Language Spoken *

Number Of Adults Residing In Household *

Number Of Children Residing In Household *

Siblings Names, Ages, Interests & Hobbies

Medical Information

Diagnosed Illness *

Date Diagnosed

Primary Oncologist

Treatment Facility

Treatment Facility Phone

Treatment Facility Fax

Social Worker's Name

Social Worker's Phone

Social Worker's Fax

Insurance Information

Is patient covered by private insurance?

Insurance Name

Is patient covered by a state funded insurance plan i.e. Medicaid?

If applicable, have you completed an application for Medicaid?

Other Information

How did you hear about MVPCC?

What other assistance have you applied for or received at this time?

Use the space below to describe medical and non-medical expenses that a grant of financial assistance could help alleviate (e.g., utility bills, transportation, etc.). Please list most urgent needs first.

PLEASE CAREFULLY READ THE FOLLOWING INFORMATION

MVPCC does not discriminate against or deny aid because of your race, religion, color, national origin, sex, political affiliation or any other protected category under state or federal law.
Your application will be reviewed on a case-by-case basis. A final determination for financial assistance is subject to availability of funds and adherence to MVPCC guidelines.
The information provided to MVPCC will be used solely for the purpose for which it was provided and will be kept confidential.
MVPCC does not have any agreements with medical providers to refer patients to providers, nor would MVPCC be willing to enter into any such agreement. MVPCC cannot and will not provide advice to our clients concerning (1) what treatment to pursue; (2) from which medical providers to seek treatment; (3) insurance coverage for treatments prescribed and/or received; or (4) any other decision affecting the health and/or medical treatment of our clients. MVPCC encourages all clients to conduct their own research as to appropriate pediatric oncology treatment, and to make their own decisions concerning these issues.
MVPCC cannot and will not provide tax or legal advice.

GENERAL RELEASE OF LIABILITY AUTHORIZATION FOR RELEASE AND USE OF MEDICAL RECORDS AND MEDIA CONSENT

The undersigned (“Releasor”) has requested assistance from Magic Valley Pediatric Cancer Coalition (“MVPCC”), a non-profit charitable organization. In making such request, Releasor understands and acknowledges that the granting of assistance is entirely discretionary and that MVPCC may deny such assistance at any time for any reason. Releasor hereby agrees to waive any and all claims against MVPCC and release MVPCC from any and all liability which may arise from MVPCC’s conduct in consideration of this Application for Assistance.

Releasor authorizes MVPCC to release and utilize patient’s medical information as it relates to MVPCC’s non-profit activities. If Releasor is 18 years of age, or upon turning 18 years of age, Releasor authorizes MVPCC to speak with and release information regarding the services provided by MVPCC to Releasor’s spouse, parents, guardian, and/or other individual(s) listed below. Releasor acknowledges that this release will remain valid and in place unless and until revoked by Releasor in writing.

First Name

Last Name

Relationship

Phone

First Name

Last Name

Relationship

Phone

Consent *

Releasor consents to the dissemination and use of the patient’s name, likeness, and recorded voice singularly or in conjunction with other photographs and/or recording by the print, television, and radio media, for the purposes of pediatric cancer awareness and for raising funds to further the goals of MVPCC (“media consent”). Releasor acknowledges that s/he has the right to revoke this media consent at any time in writing signed by Releasor. The revocation will only be effective upon receipt by MVPCC.

Signed By:

First Name *

Last Name *

Relationship to Child *