SJCCF Application For Financial Assistance 2012

Stevie JoEllie’s Cancer Care Fund
c/o Wilma Colon Ariza, Founder
649 McBride Avenue Suite No. 1
Woodland Park, NJ 07424
Email: sjccfthynet@gmail.com
Tel. 973.619.9360

APPLICATION FOR FINANCIAL ASSISTANCE

IMPORTANT NOTICE

This application is your request for an “Access to Care Grant” or “Essential Needs Assistance”
Unfortunately, submitting an application does not guarantee funds will be available to assist you.
Please be advised that our grants area based on a needs assessment and availability of funds. We
will make every effort to assist you, and in some cases will help you access other programs and
services you may be entitled to, through collaborative partnerships and referrals to other patient
care assistance agencies. All applications must be fully compliant with all application
requirements before they can be accepted for consideration by SJCCF. Keep a copy for your
records.

1. All applications for assistance will be accepted between April and October each year.
2. Only complete, “legible” applications containing ALL required information, bill copies and
other necessary documentation will be considered for assistance.
3. Applications with incomplete sections, and/or missing supporting documents will be
returned to sender. Applications we cannot read will also be returned.
4. If you are requesting “Essential Needs Assistance” you must include a copy of the bill you
need assistance with and Section 6 must be completed by a Social Worker (not an “intern”
or volunteer) from a local community assistance agency.
5. Essential Needs Assistance Grants are paid directly to service provider only.
6. Section 7 must be completed by your doctor –not office manager, secretary or nurse.
7. Due to limited staff and funding sources it may be a month or more before we can review
your application for services.
8. In some cases will help you access other programs and services you may be entitled to,
through collaborative partnerships and referrals.
9. Mail completed applications to the address that appears above

Stevie JoEllie's Cancer Care Fund is a Project of United Charitable Program Inc., a 501(c)(3) Public Charity Tax ID # 20-4286082
Program #102442 Donations are tax deductible as allowed by law and all funds raised by Stevie JoEllie's Cancer Care Fund are
received by United Charitable Programs and become the sole property of UCP, which, for internal operating purposes, allocates the
funds to the Project (SJCCFThyNet). The Program (SJCCFThyNet) Manager makes recommendations for disbursements which are
reviewed by UCP for approval.

Tel. 973.619.9360


Date:________________

Section 1: Patient Information
PLEASE PRINT

Last Name:_____________________________ First Name:_______________________________

Address:_________________________________________________________________________

City______________________________________State_____________Zip Code______________

Home Phone_______________________________ Mobile________________________________

Work Phone_______________________________ Email__________________________________

D.O.B.________________ Age________ Sex: Male ( ) Female ( ) Transgendered ( )

If patient/applicant is a minor please indicate name of parent or guardian

1. Have you applied for assistance from Stevie JoEllie’s Cancer Care
Fund before? No ( ) Yes ( ) If yes, Date ______________ Program: Access to Care ( )
Essential Needs ( )
2. Did you receive assistance from Stevie JoEllie’s Cancer Care Fund?
No ( ) Yes ( )
If the answer is yes, please state date______________Amount_________
3. If SJCCF provided referral services ONLY please briefly describe
referral results
____________________________________________________________________
____________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Prior grant assistance recipients are encouraged to wait 90 days before new re-application

Tel. 973.619.9360

Section 2: Financial Information
A. FAMILY ASSETS AND EXPENSES: (please attach the following supporting documents)
 Copies of current bill statements for items below that you would like SJCCF to consider paying.
 Family Assets Verification: Include most recent bank statements for 2 months for all household members.
 Income Verification: Last 4 pay stubs or 2 Month Business Income Statement. DO NOT SEND TAX RECORDS.
 If unemployed please provide unemployment award notice or termination of benefits verification

Monthly Expenses Amount Totals Family Assets Amount Totals
Health Insurance Premiums $ Checking Account $

Medical Bills $ Savings Account $

Prescription Costs $ Certificate of Deposit $

Transportation $ Money Market Acct. $

Child Care $ Stocks $

Mobile Phone $ Bonds $

Mortgage/Rent $ IRA $

Home: Electric $ 401K $

Home: Gas $ Income Property $

Home: Water $ Business Income $

Home: Phone $ Other (specify) $

Home: Cable $ $

Average Food Cost $ $

MONTHLY EXPENSES TOTAL $ FAMILY ASSETS TOTAL $

Tel. 973.619.9360

B. INCOME SOURCES:
Please Check All That Apply and Provide Copies of Appropriate Supporting Documents

( ) Social Security Retirement ( ) Short Term Disability Benefits ( ) Retirement Pension
( ) SSD -Social Security Disability ( ) Sick Leave Pay ( ) Alimony
( ) SSI -Supplemental Security Income ( ) Employment Wages ( ) Child Support
( ) Public Assistance ( ) Unemployement Benefits ( ) Family & Friends Support
( ) Homeless Shelter ( ) Other (Explain)

Total Household Dependents: _______ Adults:___ Children:___ Infants:___ Elderly____

Total Monthly Family Income From All Sources: _____________________

Are You or Your Spouse Currently Employed? Yes ( ) No ( ) If yes please answer the following:

Employer:_____________________________________ Length of Employment________________

Position:______________________________________ Union Member? Yes ( ) No ( )

Where else have you applied for assistance? ___________________________________________

________________________________________________________________________________

Are you now or will you be receiving assistance from another organization(s)? Yes ( ) No ( )

If yes please provide details or contact name and number of organization or casemanager below

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

If you were denied assistance by another organization or agency please briefly explain why below

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Tel. 973.619.9360


Section 3: Health Insurance Information

Do you have health insurance? Yes ( ) No ( ) If yes, please indicate type of insurance below

You must check all that apply
( ) Medicaid HMO ( ) Medicare Only ( ) VA Health Benefits
( ) Medicaid Direct Access ( ) Medicare & Medicaid ( ) Private Insurance PPO
( ) Medicaid Medically Needy ( ) Medicare & Supplement ( ) Private Insurance HMO
( ) Medicaid Pending ( ) Charity Care Program ( ) Health Exchange Network

Are prescription drugs covered under your healthcare policy? Yes ( ) No ( )

If YES, are out of pocket expenses like your prescription insurance deductible and prescription co-
pays and/or prescription medications not covered by your insurance listed in Section 2, under
Family Expenses & Medical Bills? Yes ( ) No ( )

Section 4: Essential Needs Assistance Section (Non-Medical Only)

1. Please list the exact needs for which you are requesting assistance, include costs and attach
bills. Please continue to pay your bills or negotiate bill reduction and late payment until you
hear back from us about your application. If you have any questions please call our office.
2. Please Note: we do not provide mortgage, rent, utility bill payment or food assistance.
Essential Need Item Cost Comments

Tel. 973.619.9360


Section 5: Signature of Applicant or Person Completing Application

I certify that to the best of my knowledge the information contained in Sections 1, 2, 3, and 4 of this
application is accurate and complete. I hereby give permission for applicant’s Essential Needs
Assessment information requested in Section 6 and medical information requested in Section 7 of this
form to be released and shared with Stevie JoEllie’s Cancer Care Fund pursuant to this request for
financial and referral assistance from said agency.

Signature:___________________________________ Dated: _______________________

Printed Name:______________________________________________________________

Relationship to person applying for assistance:

Self ( ) Spouse ( ) Parent ( ) Guardian ( ) Friend ( ) Caregiver ( ) Other ( ) Specify__________

Section 6: Referral Agency or Social Worker Contact Information

Please Print
Name: ______________________________________ Title_______________________________

Organization Name_______________________________________________________________

Address____________________________________City________________State_____Zip______

Phone ( ) __________________ Fax ( ) ______________ Email___________________________

Are you providing other services to this client other than assistance with this application? No ( )

Yes ( ) Please Explain ______________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Signature: ____________________________________ Dated_________________________

Tel. 973.619.9360


Section 7: MEDICAL VERIFICATION FORM
Must be completed by Endocrine Specialist or Oncologist

Date of Thyroid Cancer Diagnosis____________________ Newly Diagnosed ( ) Recurrence ( )

Type and Stage of Thyroid Cancer: __________________________________________________

Active Thyroid Cancer Treatment: Yes ( ) No ( ) If the answer to whether this patient is in active
treatment is YES, please indicate type of treatment below. Please check all that apply.

( ) Diagnostic Laboratory ( ) Hormone Replacement ( ) Bone Marrow Transplant

( ) Diagnostic Imaging ( ) Chemotherapy ( ) Stem Cell Transplant

( ) Surgical Follow Up ( ) External Beam Radiation ( ) Clinical Trial

( ) Radioactive Iodine ( ) Additional Surgery ( ) Palliative Care

If the answer to whether patient is in active treatment is NO, is post treatment follow up needed?
Yes ( ) No ( ) If the answer to whether post treatment follow up is needed is YES, please
indicate type of follow up: Monthly ( ) Every Six Months ( ) Yearly ( ) Other ( ) Please explain:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Doctor Name (please print) __________________________________________________________
MD License #___________________Clinical Specialty____________________________________
Hospital/Clinic / Facility or Practice Name_______________________________________________
Address______________________________City ___________________State______Zip________
Email______________________________Phone__________________ Fax___________________
Doctor Signature______________________________________________ Dated_______________

Tel. 973.619.9360


Section 8: Additional Comments & Notes Section

In the space provided here please tell us a little about yourself and include any relevant information
you feel will help us determine your eligibility priority for assistance.

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SJCCF Application For Financial Assistance 2012

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