weeks for the completion of your case. PATIENT INFORMATION LAST NAME FIRST NAME MIDDLE INITIAL STREET ADDRESS CITY ZIP CODE HOME PHONE CELL PHONE WORK PHONE OTHER EMAIL ADDRESS DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY # GENDER Please provide proof of identification & copy of social security card.<br><br> For non native-born applicants, please provide proof of legal residency (i.e. copy of Permanent Resident Card, U.S.-issued passport). MARITAL STATUS Single ____ Married ____ Separated ____ Divorced ____ Widowed ____ If married, spouse 9s name ______________________________________________________ MINOR OR ADULT CHILDREN NAME 1.<br><br> RELATIONSHIP TO YOU AGE GENDER M / F LIVES W/ YOU? Y / N 2. M / F Y / N 3.<br><br> M / F Y / N 4. M / F Y / N 5. M / F Y / N MEDICAL INFORMATION MEDICAL INSURANCE CARRIER GROUP NUMBER TELEPHONE NUMBER PATIENT 9S RELATION TO INSURED (circle one) SELF SPOUSE PARENT CHILD TO BE COMPLETED BY YOUR DOCTOR: CURRENT CANCER DIAGNOSIS & STAGE REOCCURENCE?<br><br> YES NO DATE OF DIAGNOSIS TO BE COMPLETED BY YOUR DOCTOR: CANCER-RELATED MEDICATIONS CURRENTLY TAKEN TO BE COMPLETED BY YOUR DOCTOR: OTHER CANCER-RELATED TREATMENTS DOCTOR INFORMATION (HIPPA Release) [45 C.F.R. § 164.508 (c)(ii) & Civ. Code § 56.11 (c)] MEDICAL ONCOLOGIST (CANCER DOCTOR) DIRECT OFFICE PHONE RADIATION ONCOLOGIST (IF APPLICABLE) DIRECT OFFICE PHONE MEDICAL ONCOLOGIST 9S SIGNATURE DATE OF SIGNATURE PATIENT 9S SIGNATURE (authorizes release of medical information) DATE OF SIGNATURE Description of the information to be released [45 C.F.R.<br><br> § 164.508 (c)(i) & Civ. Code § 56.11 (d) & (g)] Telephonic conference and/or faxed documents between Beckstrand Cancer Foundation, the above listed patient and doctor 9s office regarding patient 9s medical diagnosis, current treatment and history. Description of each purpose for the use or release of the information [45 C.F.R.<br><br> § 164.508 (c)(iv)] This information will be used for the sole purpose of evaluating the above patient for support services offered by Beckstrand Cancer Foundation. This HIPPA release is valid for a 180-day period from the patient 9s signature date shown above and only if signed by both the patient & oncologist 9s office. WORK HISTORY MOST RECENT EMPLOYER JOB TITLE HRS.<br><br> PER WEEK CURRENTLY WORKING? IF NOT, LAST DAY OF WORK MONTHLY INCOME (when working) MOST RECENT EMPLOYER OF SPOUSE JOB TITLE HRS. PER WEEK CURRENTLY WORKING?<br><br> IF NOT, LAST DAY OF WORK MONTHLY INCOME (when working) FULL DISCLOSURE IS NEEDED FOR YOUR APPLICATION TO BE CONSIDERED Please note that no response to the question of monthly income may be the basis for disqualification. If the applicant is a minor or dependent adult, please state the income of the patient's parents or guardian. MONTHLY INCOME Asterisks (**) = Proof required where indicated (if applicable).<br><br> 1. CURRENT WAGES / SALARY** 1. $ 2.<br><br> SPOUSE 9S WAGES / SALARY** 2. $ 3. CHILD SUPPORT BENEFITS** 3.<br><br> $ 4. ALIMONY 4. $ 5.<br><br> ROOMMATE / BOARDER 5. $ 6. VETERANS, RETIREMENT, AND/OR PENSION BENEFITS 6.<br><br> $ Have you applied for any of the following? (In the second column, please circle cA d if accepted, cP d if pending or cD d if denied.) If accepted, indicate what you are receiving each month. 7.<br><br> STATE DISABILITY** A P D 7. $ 8. SOCIAL SECURITY DISABILITY (SSD)** A P D 8.<br><br> $ 9. SUPPLEMENTAL SECURITY INCOME (SSI)** A P D 9. $ 10.<br><br> SOCIAL SECURITY (OVER 65) A P D 10. $ 11. STATE UNEMPLOYMENT A P D 11.<br><br> $ 12. IN-HOME SUPPORTIVE SERVICES A P D 12. $ 13.<br><br> FOOD STAMPS A P D 13. $ 14. AFDC A P D 14.<br><br> $ 15. OTHER A P D 15. $ TOTAL MONTHLY INCOME (Lines 1 3 15) $ BALANCE CURRENTLY IN: Bank Checking Account** $ ____________________ Bank Savings Account** $ ____________________ IRA or 401K $ ____________________ MONTHLY EXPENSES Asterisks (**) = Proof required where indicated (if applicable).<br><br> 1. MORTGAGE** or RENT** Circle one; provide proof with a cancelled check or receipt. 1.<br><br> $ If renting, list landlord name, phone number & name of apartment complex (if applicable) directly below: 2. GAS 2. $ 3.<br><br> ELECTRIC 3. $ 4. WATER 4.<br><br> $ 5. PHONE 5. $ 6.<br><br> FOOD 6. $ 7. AUTO: Monthly payment** (Make __________________________ Yr.<br><br> _________ ) 7. $ 8. AUTO: Monthly gasoline 8.<br><br> $ 9. AUTO INSURANCE** 9. $ 10.<br><br> HEALTH INSURANCE PREMIUM** How often paid (if not monthly)? 10. $ 11.<br><br> MEDICATIONS Cancer-related or other chronic conditions 11. $ 12. CO-PAYMENTS 12.<br><br> $ 13. MEDICAL EXPENSES NOT COVERED BY INSURANCE 13. $ TOTAL MONTHLY EXPENSES (Lines 1 3 13) $ Do you receive monetary support from other sources (friends, family, religious communities)?<br><br> Please explain: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Please provide emergency contact information for one person the patient has regular contact with: Name ____________________________________________________ Relationship to Patient _____________________ Home Phone ______________________ Cell Phone ______________________ Email Address _________________________ If you are a non-English speaker, please provide the name and phone number of a relative or friend whom we may contact to translate. Name ____________________________________________________ Relationship to Patient _____________________ Home Phone ______________________ Cell Phone ______________________ Email Address _________________________ Who referred you to Beckstrand Cancer Foundation? Name _________________________________________________ Phone Number _______________________________ Organization/ Agency & Position __________________________________________________________________________ Please add any comments or information you would like Beckstrand Cancer Foundation to know: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ For administrative purposes, organizations involved with your case may be contacted to verify the information you have provided on this application.<br><br> With your signature, you acknowledge and agree to the above stipulations. Signature _____________________________________________ Date _________________________ Before you submit your application, did you remember to include the following? o Medical information completed & signed by your oncologist, followed by your signature?<br><br> o Proof of monthly income in the form of wages, State Disability, SSD and/or SSI? o Proof of your monthly bank account statements (checking and/or savings, if applicable). o Proof of monthly rent or mortgage?<br><br> If paying rent, two consecutive months of paid rent must be provided. o If renting, did you provide the name & phone number of your landlord? o Proof of monthly auto payment?<br><br> (if applicable) o Proof of monthly auto insurance? (if applicable) o Proof of monthly health insurance premium? (if applicable) o Proof of legal residency (i.e.<br><br> Permanent Resident Card, U.S.-issued passport) You MUST provide proof of all above items (as they apply to you) to complete your case. EFFECTIVE JANUARY 1, 2009: Incomplete cases will be given a three-week grace period to allow for completion; applications still incomplete at the end of three weeks will be closed, and the applicant must re- apply for assistance consideration. BECKSTRAND CANCER FOUNDATION [45 C.F.R.<br><br> § 164.508(c)(iii) & Civ. Code § 56.11(f)] Lil Spitzer " Executive Director Pam Kennedy, MSW, LCSW " Patient Care Director Sarah Unke " Office Manager

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