application checklist please check off each item ......application checklist name of applicant:...

APPLICATION CHECKLIST

Name of Applicant: ________________________________________

All of the following items must be included in your application package. If they are not, processing may be delayed.

Please check off each item enclosed and include this sheet in your package.

Check Document or Description

Completed application with all consent forms (attestation, reimbursement form, and authorization of disclosure of protected health information)

A signed letter or verbal confirmation from a medical professional confirming diagnosis and treatment plan

The front page of your tax returns from the previous year (*If last year’s return is not yet available, (due to IRS due dates and/or extension requests), submit the return from the previous year (i.e.: 2 years ago). If married and file separately, submit both returns. If tax return not filed, submit all W-2s and 1099 forms from the previous year. *If tax return not filed, please attest below.

Completed NCCN Distress Thermometer

Documentation of health insurance premiums you wish considered for payment. (INSURANCE PREMIUM PROGRAM ONLY)

APPLICANT’S SIGNATURE: _____________________________________________ DATE: ________________

MAIL OR FAX YOUR COMPLETED APPLICATION and all required documents to:

Gateway to Hope 425 N. New Ballas Rd Suite 220 Creve Coeur, MO 63141 Or Fax: 314-432-3303 Or Email: [email protected]

Check if applicable: I attest that I have not filed taxes for the last 2 years.

GATEWAY TO HOPE PROGRAM APPLICATION

NAME: __________________________________________ TODAY’S DATE: ______________

DATE OF BIRTH: ______________ AGE:______ MARITAL STATUS:_________ RACE/ETHNICITY:______ ADDRESS: __________________________CITY:______________ STATE:_________ZIP:________

COUNTY:______________PHONE: HOME _________________ CELL___________________ WORK/OTHER____________

EMAIL:__________________________ OCCUPATION: _____________________ COMPANY: ______________________ INSURANCE: Y ____ N ____ INSURANCE TYPE:_________ #PERSONS COVERED:_____ MONTHLY PREMIUM AMOUNT:_____

INSURANCE COMPANY: ________________POLICY HOLDER NAME:_____________ EMPLOYMENT STATUS: __________________HOUSEHOLD INCOME: ANNUAL/MONTHLY ______________ SOURCE OF INCOME: ___________________________# OF PERSONS IN HOUSEHOLD: ___________

TREATMENT INFO: DIAGNOSIS AND STAGE: _______________________________ GENETIC TESTING: (CIRCLE IF COMPLETED) BRCA 1 +/- BRCA 2 +/-

BIOPSY DATE: ___________ FACILITY:_____________________________________(ER + / - ) ( PR + / - ) (HER2 + / - ) (PLEASE CIRCLE )

SURGERY INFO: PHYSICIAN: ___________________ FACILITY: ___________________ PHONE #: __________________

PROCEDURE: __________________________(LUMPECTOMY OR MASTECTOMY) (LEFT/RIGHT/BILATERAL) DATE: ________________

RECONSTRUCTIVE SURGERY:PROCEDURE & DATE:_________________________PHYSICIAN:___________________ FACILITY:___________________

MEDICAL ONCOLOGY INFO: PHYSICIAN:_____________________ FACILITY:_______________________ PHONE #:__________________________

TREATMENT PLAN:__________________________________________________________________________________________________

NEO-ADJUVANT (BEFORE SURGERY) START DATE: ________________DATE COMPLETED: ______________

ADJUVANT (AFTER SURGERY) START DATE: ____________________DATE COMPLETED: _____________

RADIATION ONCOLOGY INFO: PHYSICIAN: ____________________FACILITY:_______________________PHONE #:___________________________

# OF TREATMENTS PLANNED: __________ START DATE:______________ DATE COMPLETED: ________________

REFERRAL SOURCE: NAME: ______________________________TITLE (IF APPLICABLE): ________________FACILITY (IF APPLICABLE): ________________

SOCIAL WORKER/CASE WORKER/NURSE NAVIGATOR (OPTIONAL): NAME: ____________________________PHONE #: ___________________________

PATIENT’S SIGNATURE: ________________________________________________________ DATE:_______________________________

Optional. Used for grant funding purposes only

Thelma’s

IPP

Thelma’s &

IPP

Lymphedema

For Office Use Only Patient FPG: ________________ Eligibility Status: ____________ Date: __________________ Notes:

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Applicant Financial Information:

Complete financial information is required on all household members

Household Assets Monthly Household Expenses

Checking Account. $ Rent Mortgage $

Savings Account $ Phone(s) $

Retirement Assets (e.g. 401k, IRA) $ Utilities $

Stocks & Bonds $ Transportation

Auto Payment(s) $

Monthly Household Income Auto Insurance $

Gross Monthly Wages $ Medical Expenses

Spouse’s Monthly Income $ Health Insurance $

Additional Household Income $ Misc. (Specify) $ _____

Child Support $ Misc. (Specify) $

Alimony $

Food Stamps $

SSI/SSD benefit $

Veterans benefits $

Other (Specify) $

Total Monthly Income $

Applicant Attestation

In consideration for acceptance into the Gateway to Hope Insurance Premium Program (Program), I agree and

certify as follows:

1. I attest that the information provided is complete and accurate to the best of my knowledge.

2. I have read, understand and agree to abide by the Program Guidelines.

3. I understand that while every effort will be made to provide assistance, the Program is limited to

the availability of funds and I may not receive assistance even if I satisfy the eligibility

requirements and the other terms and conditions in the Program Guidelines.

4. I understand the Program Guidelines could be modified at any time and the Program could be discontinued at

any time.

5. I understand that GTH has the right to audit my eligibility and the accuracy of any documents or information I

provide and to request that I provide any additional information. I understand that if I desire to receive

assistance beyond the original grant term, I will be required to submit updated information to GTH.

6. I understand that GTH will have the right to terminate any assistance granted if GTH becomes aware that any

information provided in this application is not accurate, if I do not provide any information requested by GTH

or if I do not meet the eligibility requirements and other terms and conditions set forth in the Program

Guidelines.

7. I will promptly notify GTH of any changes to the information I have provided to GTH.

8. I understand that I am not required to use any particular health care provider as a condition of receiving

assistance under the Program and I am free to change my health care providers at any time.

9. I acknowledge that GTH may disclose certain information from my application to my health insurance carrier,

breast cancer caregivers, pharmacists, or other parties to fulfill my grant request.

10. I understand that from time to time, GTH aggregates data from many patients to create aggregated (summary)

patient data which GTH may share with third parties, including researchers, partners, foundations, policy

makers and other funding sources to help us apply for funding, prepare reports, advocate on behalf of patients,

or perform other health related research.

11. I attest that I am not receiving financial assistance for the insurance premiums for which I am applying for

assistance under the Program. In the event I become qualified for Medicaid coverage and in connection

therewith, or otherwise, become entitled to a refund of insurance premiums, I agree that GTH shall be entitled

to receive such refunds and I will transfer any such refunds I receive to GTH immediately.

12. I understand that in no event shall GTH be liable in any way for damages alleged to result from errors or delays

in the processing of Program applications or the issuance of payments as part of the Program, my choice of

health care provider or the success or failure of any therapy or treatment I obtain using funds from the Program.

By signing below, I attest that I have read, fully understand and agree to the Applicant

attestation set forth above.

Applicant's Name (Please Print)

Applicant's Signature Date

Applicant’s Signature (REQUIRED) _________________________________________________ Date ___________

Insurance Premium Program

Premium Reimbursement Request Form

Fax COMPLETE FORM and supporting documentation 314-432-3303.

Demographic Information

Name (First Name, Middle Initial, Last Name) ___

Date of Birth _______________________________________________

Payee Information

Make Check Payable to (Name of Person, Facility or Organization): _________________________________________________ Address for payment: ______________________________________________________________________________________ Telephone ___________________ Fax _____________________ Email ______________________________

Insurance Premium information

Coverage Period _____________________________________________________________________________

Due Date _____________________________ Premium Amount Due ___________________________________

Payment Frequency (check one): Weekly ____Bi-Weekly ____ Monthly ____ Bi-Monthly _______ Quarterly _________

Reference Information to be printed on check (e.g. Patient’s insurance member ID) ______________________

To make premium payments directly to your insurance company, please submit the following along with this request form:

o Insurance Invoice or Coupon indicating coverage period to be paid, due date, and premium amount

To reimburse the patient/guardian for premium payments, please submit the following along with this request form:

o Insurance Invoice or Coupon indicating coverage period, due date, and premium amount

o Proof of Payment (submit any one of the following showing your actual payment for your premium)

o Bank statement (must show account holder’s name)

o Credit card statement (must show account holder’s name)

o Pay stubs or Cancelled Checks (must be accompanied by a bank statement)

o Medicare Part B deductions from Social Security, submit bank statement showing Social Security Deposit

o Premium deduction from Pension, submit bank statement showing pension deposit

Applicant's Declaration

I verify that the information provided in this request is complete and accurate. I further verify that to the best of my knowledge the information

presented in my original application for assistance through the Gateway to Hope (GTH) Insurance Premium Program has not changed. I understand

that I am required to notify GTH if my financial situation, insurance status, or medical condition changes from that which is reported in the original

application. I have not received any other reimbursement for the expenses for which I am seeking reimbursement from GTH, nor will I receive such

reimbursement from any source (including, but not limited to, Medicaid, or any other foundations), or a health care flexible spending account. I

understand that I must submit my reimbursement request as soon as possible after payment of my insurance

premium and that GTH will not pay claims received more than 120 days after the payment date. Finally, I understand that

GTH reserves the right at any time and without notice to modify or discontinue any or all of the programs with respect to any applicant or in their

entirety, to modify the related eligibility criteria, or to terminate assistance.

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (“PHI”)

Patient’s Name: __ Patient’s Date of Birth: __

I hereby request that my health care provider identified below disclose the PHI described below to Gateway to Hope in

connection with my application for assistance from Gateway to Hope.

Name of Health Care Provider: _______________________________________________________________

PHI To Be Disclosed: ___________________________________________________________________________________________

Acknowledgment: If my medical record contains information about drug/alcohol abuse, mental health treatment,

sexually transmitted diseases, HIV/AIDS testing/treatment or any other sensitive information, I agree to its release.

Check if you do not agree to release of sensitive information described herein: Do Not Agree

Date(s) of Service of PHI To Be Disclosed: All dates of services, unless otherwise specified below:

___________________________________________________________________________________________

Revocation Right: I understand that I have the right to revoke this Authorization at any time by submitting a notice in

writing to the above named healthcare provider at the address stated above and that the revocation will be effective except

to the extent that action has already been taken in reliance on this Authorization.

Expiration: This Authorization will expire 1 year from the date of my signature below, unless otherwise specified

herein:____________________________________

Re-Disclosure: I understand that the information disclosed by this Authorization may be subject to re-disclosure by the

recipient and no longer protected by Federal or state privacy requirements.

Signature: I understand that my treatment, payment, enrollment or eligibility for benefits may not be

conditioned on signing the Authorization. By signing this document, I hereby authorize the above named

provider to disclose my protected health information as specified in this document.

Signature of Patient or Personal Representative Date

If this Authorization is signed by the patient’s personal representative, indicate such representative’s authority

to act on behalf of the patient: _________________________________________________________________

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines® is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use, or application, and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2013.

Instructions: First please circle the number (0-10) that bestdescribes how much distress you have been experiencing inthe past week including today.

YES NO YES NOPractical Problems

Family Problems

Emotional Problems

Spiritual/religiousconcerns

Physical ProblemsChild careHousingInsurance/financialTransportationWork/schoolTreatment decisions

Dealing with childrenDealing with partnerAbility to have childrenFamily health issues

DepressionFearsNervousnessSadnessWorryLoss of interest inusual activities

AppearanceBathing/dressingBreathingChanges in urinationConstipationDiarrheaEatingFatigueFeeling SwollenFeversGetting aroundIndigestionMemory/concentrationMouth soresNauseaNose dry/congestedPain

s/feet

SexualSkin dry/itchySleepSubstance abuseTingling in hand

Second, please indicate if any of the following has been aproblem for you in the past week including today. Be sure tocheck YES or NO for each.

Other Problems: _________________________________________

________________________________________________________

SCREENING TOOLS FOR MEASURING DISTRESS

Extreme distress

No distress

10

9

8

7

6

5

4

3

2

1

0

10

9

8

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2

1

0

NCCN Distress Thermometer for Patients

Help for distress

Distress is an unpleasant emotional state that may affect how you feel, think, and act. It can include feelings of unease, sadness, worry, anger, helplessness, guilt, and so forth. Everyone with cancer has some distress at some point of time. It is normal to feel sad, fearful, and helpless.

Feeling distressed may be a minor problem or it may be more serious. You may be so distressed that you can’t do the things you used to do. Serious or not, it is important that your treatment team knows how you feel.

The Distress Thermometer is a tool that you can use to talk to your doctors about your distress. It has a scale on which you circle your level of distress. It also asks about the parts of life in which you are having problems. The Distress Thermometer has been tested in many studies and found to work well. Please complete the Distress Thermometer and share it with your treatment team at your next visit.

The Distress Thermometer helps your treatment team know if you need supportive services. You may be referred to supportive services at your cancer center or in your community. Supportive services can include help from support groups, chaplains, social workers, counselors, and many other experts. Supportive services can also be found through the support services at right.

Support Services

National Cancer Institute’s Cancer Information ServiceTelephone 1-800-4-CANCERWebsite www.cancer.gov/aboutnci/cis/page1

Cancer Support CommunityTelephone 1- 888-793-9355Website www.cancersupportcommunity.org/MainMenu/Cancer-Support

U.S. Health Resources and Services AdministrationWebsite www.findahealthcenter.hrsa.gov/Search_HCC.aspx

U.S. Substance Abuse and Mental Health Services AdministrationWebsite www.findtreatment.samhsa.gov




Family Problems

Emotional Problems






s/feet



Other Problems: _________________________________________

________________________________________________________


Extreme distress

No distress

10

9

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2

1

0

10

9

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0





Family Problems

Emotional Problems






s/feet



Other Problems: _________________________________________

________________________________________________________


Extreme distress

No distress

10

9

8

7

6

5

4

3

2

1

0

10

9

8

7

6

5

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3

2

1

0


application checklist please check off each item ......application checklist name of applicant:...

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