CAREGIVER GRANT APPLICATION Caregiver Grant Application Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home Phone*Work PhoneCell PhoneEmail* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Type of Cancer*Stage of Cancer*Date of Cancer Diagnosis*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Race / EthnicityWhiteBlack or African AmericanAmerican Indian or Alaskan NativeAsian / Pacific IslanderHispanic or LatinoOtherOther RaceHow 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 EmploymentDo you have health insurance?*YesNoIf 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 InsurancePersonal StatementWho 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HIPPA Authorization FormEntering 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 InformationMedical 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:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Fill 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Printed 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Type of Cancer*Stage of Cancer*Stage 0 (DCIS)Stage IStage IIStage IIIStage IVUnknownThis is a:*New DiagnosisLocal / Regional RecurrenceMetastaticIn Active Treatment?*YesNoIf 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?YesNoProvider Name:*Hospital/Clinic:*Address* Street Address City State / Province / Region ZIP / Postal Code Phone*FaxSignature of person completing this section:*Name* First Last Phone (if different than above):Email Relationship to Person Applying for Assistance:*DoctorNurseSocial WorkerCase WorkerOtherOther Assistance:
