Where does Circle of Hope get their money from? Small and Large Grants, Designated Donations, Fundraisers. Often times the money is donated for a specific need.
Where do the referrals come from? From doctors, physicians, oncologists, nurse navigators, social workers, cancer centers, financial workers, TV ads, other advertising.
SAMPLE Application For Block Grants (Payments) For Breast Cancer Treatment Bills
This application is only a sample of a partial application for breast cancer treatment expenses and daily living expenses. It is being offered to breast cancer clients in Northern Minnesota and Northern Wisconsin provided we have the funds for that area. The cancer centers have applications.
This would be those individuals who fall into the poverty guidelines and/or have financial distress due to their breast cancer medical, dental and prescription
bills. The patient must apply. Call 1.218.464.1626 to have an application sent to you. These payments will be be paid directly to the providers for the following services: dental (from not having teeth fixed before chemo and they need to be pulled), prescription providers, mastectomy products (Heide's), St. Luke's Clinics/Hospitals, Essentia Clinics/Hospitals, and all independent regional clinics/hospitals in northern MN and northern WI from documented bills. Circle of Hope only pays for breast cancer treatment services that are incorporated businesses after they have been run through insurance and community care programs. Circle of Hope does not pay patients.There is no guarantee that there are funds available in your county. It all depends on donors and fundraising that has taken place. That is why it is important to call, talk to the coordinator and get the application.
What is Covered?
-These block grants are for breast cancer treatments. It could include related loop hole prescription coverage, dental work related to chemo (so that ones teeth
doesn't rot out from having chemo), bone infusions, lab work, surgery, reconstruction of the affected breast (s), radiation, chemo, physician (oncology, surgeon, radiation)
bills related to all of the above. These bills must be related to breast cancer treatment. These payments are based on "Needs" and Not Wants. (Proven treatments
and medical procedures that are needed and highly recommended should be included.)
Who Qualifies For Financial Help?
-Children, teens, women, men, and women who have breast cancer and can verify their financial need based on poverty guidelines and/or financial distress.
How is the Money Raised?
This money is being raised from grants, private donors, organizational donors, businesses, fundraising and a variety of resources.
How Does One Get Selected for A Breast Cancer Block Grant?
The Circle of Hope board will be evaluating and voting on these applications based on "a financial/needs criteria grid."For confidentially, the board
has decided that the secretary will be the only one who knows the name of the individual who have submitted applications. We do not ask for individuals ages. Each application is assigned number.
How Much Are The Block Grants?
The block grants are breast cancer medical bills up to $2,000.00 per year. Please only apply once a year, unless asked to do so again. (We do not plan on holding on to our financial resources, as no one is paid a salary.)
How Much Are Daily Living Grants?
These are based on real need and can be up to $1500.00 if available for that area. All donations are for designated areas by the donors.
If I Do Not Qualify; How Can I Get Additional Help With Other Financial Resources or a Benefit?
For those who do not qualify, we can still help you with resources. You can look under our Resources tab on our website, which is constantly being updated
with additional resources. There are local people who can help you as well. We have many other resources other than those listed on our website. Just call our
secretary, Peggy at 1.218.464.1626 (office).
If I Want To Run Off The Forms and Send Them In; Who Do I Send Them To?
If you need help filling out this form contact our secretary, email@example.com who will be more than willing to help you. Her contact information is:
Circle of Hope, 5204 Otsego St., Duluth, MN 55804. The phone number is 1.218.464.1626. Paper copies are available at clinics or can be mailed to
you. If you want to do it on- line, the forms are below. You still need to send in the bill by mail with this Authorization for Use or Disclosure of
Information, filled out by you and with your signature.
*****PLEASE CALL TO HAVE AN APPLICATION SENT TO YOU (1.218.464.1626.)
The applications are updated all of the time.
THIS APPLICATION DOES NOT COPY WELL BY THE SUBMITTER OF THE APPLICATION.
THE APPLICATION HAS CHANGED.
DO NOT USE THE FOLLOWING FORM.
Circle of Hope-AUTHORIZATION FOR USE OR DISCLOSURE OF INFORMATION
To: Circle of Hope: Administrative Staff and Necessary Board Members
____I hereby request and authorize the disclosure of the following information to the Circle of Hope as part of my application for support services.
____I hereby authorize the disclosure of the following information to necessary staff and board members of Circle of Hope:
____Medical Records and services received relating to the funding request
____Other (Please specify)___________________________________________
Purpose Statement: the purpose of this authorization is to enable Circle of Hope to be informed and assess the medical services provided to assist in the financial support of my medical needs.
I know and understand:
. Information pertaining to myself and my medical condition are protected under state and federal laws and generally cannot be disclosed or
re-disclosed without my consent with certain exceptions specified by law.
. I am under no obligation to sign this authorization, however, without authorization I am ineligible for financial support from "The Circle of Hope."
. I may revoke this authorization at any time by giving written notice of revocation. Unless previously revoked this authorization expires twelve (12)
months from the date of the signature. Revocation of authorization will result in termination of financial support.
. Revocation of this authorization does not apply to information already released under this authorization.
SAMPLE-The Application is Below and Expands When You Write On It On-Line. DO NOT USE THIS FORM.