Application For Block Grants (Payments) For Breast Cancer Treatment Bills
This application is for breast cancer treatment expenses and is being offered to breast cancer clients in Northern Minnesota and Northern Wisconsin. 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. There maybe other items covered, as we know there are always exceptions to any policy or rule. These payments will be be paid directly to the providers for the following services: dental, prescription providers, St. Luke's Clinics/Hospitals, Essentia Clinics/Hospitals, and all independent regional clinics/Hospitals from documented bills.
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 don't rot out from having chemo), bone infusions, lab work, surgery, reconstruction of the affected breast (s), radiation, chemo, physican (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 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 and we do not rent an office space. 100% of block grant money goes to patients in need. You can look on our link, Helping Hearts and Hands to see the accounts.)
If I Do Not Qualify; How Can I Get Additional Help Wth 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 1.218.525.1905.
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, peggy@circleofhopeduluth.org who will be more than willing to help you. Her contact information is: Circle of Hope, 5204 Otsego St., Duluth, MN 55804. Her phone number is 1.218.525.1905. 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.
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PLEASE RUN OFF THIS FORM AND SEND IT IN WITH YOUR BILL(S):
Circle of Hope-AUTHORIZATION FOR USE OR DISCLOSURE OF INFORMATION
To: Circle of Hope: Administrative Staff and Necessary Board Members
Re: Name:_________________________________________________________
Maiden/Other Name:________________________________________________
____I herby 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
____Intake/Admission Information
____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 previouusly 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 relased under this authorization.
Client Signature_____________________________________________________
Date:_____________________________________________________________
The Application is Below and Expands When You Write On It On-Line:
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