P.M Financial

Dear CancerCare Client,

Thank you for contacting CancerCare to request a financial assistance application. Please complete the patient sections on pages one and two and ask your oncology doctor, nurse or social worker to complete the medical information section on the first page. Patients or family members cannot complete the medical information section of the form. Applicants must meet financial eligibility criteria and provide proof of income as follows:

NATIONAL 275 SEVENTH AVENUE, NEW YORK, NY 10001 WWW.CANCERCARE.ORG T: 212-***-**** OR 800-813-HOPE (4673) F: 212-***-**** E: ****@**********.*** Please return this form and the requested documents as soon as possible. Our funds for financial assistance are limited and based on availability and an application is not a guarantee of acceptance. Please be thorough as all sections of the application must be completed in order for your application to be considered. You may fax it to the attention of the Financial Assistance Unit at 212-***-**** or email to ***-***@**********.***. CancerCare provides free, professional support services to individuals, families, caregivers, and the bereaved to help them better cope with and manage the emotional and practical challenges arising from cancer. Our services include counseling and support groups, educational publications and workshops, and financial assistance. All of our services are provided by professional oncology social workers and are offered completely free of charge. If you have any questions about this form or need assistance in completing it, please call 800-813-HOPE (4673). Our hours are Monday thru Thursday, 9:00 a.m. – 7:00 p.m., and Fridays from 9:00 a.m. – 5:00 p.m. Eastern Time. You can also visit our website at www.cancercare.org. All information is strictly confidential and for CancerCare use only. Sincerely,

CancerCare

A-1

Acceptable Proof of Income

• The first two pages of signed copy of income tax return

(You may 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 000******* / Jeannine Spang

PATIENT INFORMATION (please print clearly)

First name: Last name: Today’s date:

Address:

City, County, State, Zip:

Phone Number: Home Work Cell Email Address

Date of birth: If patient is a minor (under 18), name of parent or guardian: o Male o Female

Race: o American Indian or Alaska Native o White o Asian o Black/African American o MENA (Middle Eastern and North Africa) o Native Hawaiian or Pacific Islander o Unspecified Ethnicity: o Colombian o Cuban o Dominican o Mexican/MexicanAmerican o Chicano o Puerto Rican o Salvadoran o Other Hispanic/Latino/Spanish Origin o Not of Hispanic/Latino/Spanish Origin

275 Seventh Avenue, Floor 22, New York, NY 10001

phone: 800-813-HOPE (4673) I fax: 212-***-****

email: ***-***@**********.*** I website: www.cancercare.org Application for Financial Assistance

Please have all pages

completed, signed and

returned with proof of income.

Medical information must be

completed by provider only.

[Incomplete applications cannot be accepted] PAGE 1 OF 3 THIS SECTION TO BE COMPLETED BY THE PATIENT/PERSON REQUESTING FINANCIAL ASSISTANCE HEALTH INSURANCE INFORMATION

Does the patient have health insurance? o Yes o No If yes, please indicate type of insurance (check all that apply): o Private insurance o Medicaid o Medicare o Medicare plus Medigap o Charity care o VA program o Emergency Medicaid o Medicaid Pending o Medicare and Medicaid o Medicare and Supp o Public Health lnsurance o Unknown

Are prescription drugs covered? o Yes o No

HOUSEHOLD FINANCIAL INFORMATION

Is patient currently employed? o Yes o No Number of people in household: FAMILY INCOME SOURCES (please check all that apply): o Social Security (retirement) o Salary o Pension o Unemployment o Public assistance o Short-term disability o SSD (Disability) o SSI o Family/friends provide support o Other—specify

000******* / Jeannine Spang

APPLICANT’S NAME: DOB:

THIS PAGE TO BE COMPLETED BY THE PATIENT/PERSON REQUESTING FINANCIAL ASSISTANCE Please be aware that funds are limited, and based on availability as well as on meeting CancerCare’s eligibility requirements. Our grants are not for living expenses such as rent, mortgages, utility payments or food, and we do not provide grants for medical bills or insurance co-payments. If you need this type of assistance, one of our social workers may be able to refer you to a local agency for help. FINANCIAL ASSISTANCE NEEDS (check all that apply): I need help with the following cancer-related expenses: o Transportation o Child care o Home care o Pain medications o Lymphedema supplies (breast cancer only) For breast cancer patients only:

o Oral pain medication o Oral anti-nausea medication o Oral chemotherapy o Oral Hormone Therapy o Eldercare o Palliative care o Durable medical supplies

For pancreatic patients only:

o Insurance premiums o Co pays o Biopsy o MRI o Acupuncture o Alternative Treatments o Other Signature: Date:

Relationship to person applying for help: o Self o Spouse o Family member/caregiver o Health care professional

**I ATTEST BY WAY OF MY SIGNATURE THAT ANY FINANCIAL ASSISTANCE GRANTS WHICH MAY BE AWARDED WILL BE UTILIZED FOR THE EXPENSES INDICATED ABOVE** THANK YOU.

Fax this form to 212-***-****, email to ***-***@**********.*** or mail to: CancerCare, 275 Seventh Avenue, 22nd Floor, New York, NY 10001. CancerCare will review this information and contact the person requesting financial assistance. All information is strictly confidential and is for CancerCare use only. March 2018 version 5.4 Acceptable Proof of Income

• The first two pages of signed copy of income tax return (You may 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 TOTAL ANNUAL FAMILY INCOME **:

**Application will not be processed if this information is not provided** ATTACH PROOF OF INCOME

PAGE 2 OF 3

000******* / Jeannine Spang

PATIENT’S NAME: DOB:

Date of diagnosis: Primary cancer: Current stage:

o New diagnosis o Recurrence Is patient in active treatment? o Yes o No If not in active treatment, indicate frequency of follow-up: o Yearly o Every six months o Other Please indicate type of treatment(s) received in past twelve months (check all that apply) o Chemotherapy o Radiation o Surgery o Hormonal o Palliative care o Bone marrow/stem cell transplant

*** PLEASE COMPLETE ALL FIELDS ABOVE ***

HEALTH CARE PROFESSIONAL INFORMATION (please print): MD name: Hospital/Clinic:

Address: City, State, 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: o Doctor o Nurse o Social Worker o ACS Hospital Patient Navigator Signature of MEDICAL Professional: Date:

MEDICAL INFORMATION *** THIS SECTION MUST BE COMPLETED BY YOUR ONCOLOGY NURSE, DOCTOR, SOCIAL WORKER OR HOSPITAL ACS PATIENT NAVIGATOR ONLY *** PAGE 3 OF 3

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