CAREGIVER GRANT APPLICATION

Caregiver Grant Application

Date*
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Work Phone
Cell Phone
Email*
Date of Birth*
Age*
Type of Cancer*
Stage of Cancer*
Date of Cancer Diagnosis*
Race / Ethnicity
- White
- Black or African American
- American Indian or Alaskan Native
- Asian / Pacific Islander
- Hispanic or Latino
- Other
Other Race
How did you learn about this grant?*
Which of the following describes your employment or work situation? (Check all that apply.)*
- Employed full-time
- Employed part-time
- Retired
- Short-Term Disabled/Medical Leave
- Long-Term Disabled
- Unemployed
- Student
- Other
Other Employment
Do you have health insurance?*
- Yes
- No
If yes, please indicate type of insurance: (Check all that apply)*
- Medicaid
- Private Insurance
- Medicaid Pending
- Medicare Only
- VA Program
- Medicare plus Medicaid
- Charity Care
- Public Health Insurance
- Medicare plus
- Emergency Medicaid
- Other
Other Insurance
Personal Statement
Who is Writing this statement?*
If the applicant is unable to write his/her own statements, a nominating individual can write on his/her behalf. Please state name and reason for nominee.
Please describe how your loved one’s cancer diagnosis has impacted your life.*
What are your interests, hobbies, preferred activities? What activities would make you feel livelier, positive, and in-control while taking care of your loved one as he/she undergoes cancer treatments?*
I have read the application instructions and application and discussed them with my healthcare professional. I understand the purpose of the Seas It Patient & Care-giver Grant and fully accept all terms and conditions of the fund, and all other rules, regulations and conditions set forth concerning the grant. I hereby certify that the information provided in all parts of this application is truthful. I understand that any misrepresentation or false answer can be grounds for elimination from this program.
Signature*
Date*
I understand that my health care provider may need to be contacted regarding the accuracy of the information provided and to verify my diagnosis. I give permission to the Seas It Patient& Caregiver Grant committee to contact my health care provider, understanding that the information obtained from my health care provider will not be shared with other parties, and is solely acquired for the purposes of fulfilling the grant.
Signature*
Date*
HIPPA Authorization Form
Entering your name and name of the healthcare provider in the areas below grants your healthcare provider to disclose the following protected health information to Seas It.
Patient's Name*
First Last
Information to be disclosed (check all that apply):*
- Medical Records
- Treatment Records
- Diagnostic Records
- Other
Other Disclosed Information
Medical Provider Name*
Prefix First Last Suffix
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email or Fax*
This protected health information is being used or disclosed for verification of cancer diagnosis and treatment status, in order to qualify for the Seas it Patient & Caregiver Grant.
This authorization expires on:*
Fill in date six months from application completion.
Seas It is not a health care provider or health plan covered by federal privacy regulation, and the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations. If disclosed, information would be disclosed only to entities and individuals associated with the Seas it Patient & Caregiver Grant. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment from your physician(s), or educational services or information from Seas it. You may inspect or copy the protected health information to be used or disclosed under this authorization. You may revoke this authorization in writing at any time by sending written notification to Amanda McGovern.
Signature of Participant or Personal Representative*
Date*
Printed Name of Participant or Personal Representative*
Description of Personal Representative’s Authority
(ex.: Power of Attorney)
Medical Information
To Be Completed By Physician, Nurse Practitioner, Nurse, Social Worker or Case Worker Only
Please complete all sections. Incomplete applications will not be processed.
Date*
Type of Cancer*
Stage of Cancer*
- Stage 0 (DCIS)
- Stage I
- Stage II
- Stage III
- Stage IV
- Unknown
This is a:*
- New Diagnosis
- Local / Regional Recurrence
- Metastatic
In Active Treatment?*
- Yes
- No
If Yes, which of these treatments has the applicant had in the past 6 months (choose all that apply):
- Chemotherapy
- Radiation
- Targeted / Biologic Therapy
- Hormonal Therapy
- Surgery
- Palliative Care
If No, is this patient compliant with her follow up care plan?
- Yes
- No
Provider Name:*
Hospital/Clinic:*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Fax
Signature of person completing this section:*
Name*
First Last
Phone (if different than above):
Email
Relationship to Person Applying for Assistance:*
- Doctor
- Nurse
- Social Worker
- Case Worker
- Other
Other Assistance:

Caregiver Grant Application

Personal Statement

HIPPA Authorization Form

Medical Information