Financial Support Form in English

Financial Support

The Northern Nevada Children's Cancer Foundation is able to provide financial assistance through generous grants and donations. Please complete the application below. You will be contacted by a staff member when it has been received.

Step 1 of 3

33%

PATIENT INFORMATION
Patient's Name*
Birth Date*

Date Format: MM slash DD slash YYYY
Age at Diagnosis*
Patient's Interest & Hobbies*
Gender*
- Male
- Female
- Other
GUARDIAN INFORMATION
Parent/Guardian's Name (s)*
Marital status of Parents/Guardians*
Name of Custodial Parent
Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country
Phone*

Cell Phone (Include Name) Cell Phone (Include Name) Work Phone
Email*
*

HOUSEHOLD INFORMATION
Primary Language Spoken*
# of Adults Residing in Household*
# of Children Residing in Household*
Siblings Names, Ages & Hobbies*
MEDICAL INFORMATION

Please provide all information as accurately as possible
Diagnosed Illness*
Date Diagnosed*

Date Format: MM slash DD slash YYYY
Primary Oncologist*
Treatment Facility*
Phone
Fax
Social Worker's Name
Phone*
Fax
INSURANCE INFORMATION
Is patient covered by private insurance?*
- Yes
- No
If "yes" insurance name
Is patient covered by a state funded insurance plan, i.e. Medicaid?*
- Yes
- No
If applicable, have you completed an application for Medicaid?*
- Yes
- No
OTHER INFORMATION
How did you hear about NNCCF?*
What other assistance have you applied for or received at this time?
Use the space below to describe medical and non-medical expenses that a grant of financial assisance could help alleviate:

PLEASE READ THE FOLLOWING CAREFULLY
- NNCCF does not discriminate against or deny aid because of your race, religion, color, national origin, sex, political affiliation or any other protected category under state or federal law.
- Your application will be reviewed on a case-by-case basis. A final determination for financial assistance is subject to availability of funds and adherence to NNCCF guidelines.
- The information provided to NNCCF will be used solely for the purpose for which it was provided and will be kept confidential.
Please note: NNCCF provides this list of medical providers at our clients’ request. NNCCF does not have any agreements with these medical providers to refer patients to these providers, nor would NNCCF be willing to enter into any such agreement. Rather, this list identifies medical providers who provide pediatric oncology treatments about which NNCCF is aware (listed in alphabetical order so as to avoid any appearance of NNCCF expressing a preference for one medical provider over another).
NNCCF cannot and will not provide advice to our clients concerning:
1. what treatment to pursue;
2. from which medical providers to seek treatment;
3. insurance coverage for treatments prescribed and/or received; or
4. any other decision affecting the health and/or medical treatment of our clients.
NNCCF hopes that its clients find this list to be a useful first step in locating appropriate treatment, and NNCCF encourages all clients to conduct their own research as to appropriate pediatric oncology treatment, as well as to make their own decisions concerning these issues.
GENERAL RELEASE

General Release of Liability, Authorization for Release, and Use of Medical Records and Media Consent
The undersigned (“Releasor”) has requested assistance from Northern Nevada Children’s Cancer Foundation (“NNCCF”), a non-profit charitable organization. In making such request, Releasor understands and acknowledges that the granting of assistance is entirely discretionary and that NNCCF may deny such assistance at any time for any reason. Releasor hereby agrees to waive any and all claims against NNCCF and release NNCCF from any and all liability which may arise from NNCCF’s conduct in consideration of this Application for Assistance.
Releasor consents to and authorizes the release and use of Protected Health Information, which may be protected under federal law, from all medical care facilities, insurance groups and/or social welfare agencies to NNCCF. Releasor further authorizes NNCCF personnel to speak directly with patient’s medical providers and/or social workers. Releasor authorizes NNCCF to release and utilize patient’s medical information as it relates to NNCCF’s non-profit activities.

Releasor consents to the dissemination and use of the patient’s name, likeness, and recorded voice singularly or in conjunction with other photograph’s and/or recording by the print, television, and radio media, for the purposes of pediatric cancer awareness and for raising funds to further the goals of NNCCF (“media consent”). Releasor acknowledges that s/he has the right to revoke this media consent at any time in writing signed by Releasor. The revocation will only be effective upon receipt by a NNCCF
Signature*
Date*

Date Format: MM slash DD slash YYYY
Relationship to Child*
Dates of Service*

Date Format: MM slash DD slash YYYY

Please state approximate date of service beginning

Financial Support Form in English

Financial Support

Step 1 of 3

PATIENT INFORMATION

GUARDIAN INFORMATION

HOUSEHOLD INFORMATION

MEDICAL INFORMATION

INSURANCE INFORMATION

OTHER INFORMATION

PLEASE READ THE FOLLOWING CAREFULLY

GENERAL RELEASE