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 Circle of Hope is a member of the Minnesota Better Business Bureau Association since January 7, 2016.
Circle of Hope, Non Profit Organizations General Membership, Duluth, MN


Circle of Hope has its financials on Guide Star: www.guidestar.org














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, 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. 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
 
Re: Name:_________________________________________________________
 
Maiden/Other Name:________________________________________________
 
____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
 
____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 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.
 
Client Signature_____________________________________________________
 
Date:_____________________________________________________________
 
SAMPLE-The Application is Below and Expands When You Write On It On-Line. DO NOT USE THIS FORM.
----------------------------------------------------------------------------------------------
Name (Full Name)
Maiden Name and/or Other Names
I herby request and authorize the disclosure of the following information to the Circle of Hope as part of my application for support services. Yes or No
I hereby authorize the disclosure of the following information to necessary staff and board members of Circle of Hope. Yes or No
Medical records and services received related to the funding request. Yes or No
Intake/Admission Information. Yes or No
Other (Please specify) Yes or No
Client's signature:
The Full Date of the Application:
Enter the code shown:

Date
Full name
Full and complete address
Telephone number
E-mail address
A provider who we can contact
Annual gross family income for the past year
Please state your financial need area
Why you need the money
Last 4 of your social security
What other financial resources have you tried to access for your bills
Are you involved with any other organization that can help you financially
Have you asked other organizations for help
Have you had a benefit or are you planning a benefit
Are you covered under health insurance
What type of health insurance do you have
What is your deductible
Do you pay house payments on your home
Have you enclosed a photocpy of your bill to be paid
What is your net income
How many people live in your home
Please sign your name or send your signature in the mail, if you are unable to do it electronically
Enter the code shown: