Heather Baker Foundation
APPLICATION FOR FINANCIAL ASSISTANCEAPPLICANT’S NAME: AddressCity, State, ZipPhoneEmailPATIENT’S NAME: AddressCity, State, ZipPhoneEmailDate of BirthIf patient is a minor (under 18), name of parent or guardian?Male ?FemaleMEDICAL INFORMATION Date of diagnosis: _____________ Primary cancer: ______________________ Stage ________ ?New diagnosis ?Recurrence Is patient in active treatment? ?Yes ?No If not in active treatment, indicate frequency of follow-up: ?Yearly ?Every six months ?Other_________ Please indicate type of treatment(s) received in past twelve months (check all that apply) ?Chemotherapy ?Radiation ?Surgery ?Bone marrow/stem cell transplant ?Other ____________HEALTH CARE PROFESSIONAL INFORMATIONMD name: ____________________________________ Hospital/Clinic: ______________________________________ Address: _____________________________________ City, State, Zip: _______________________________________ Phone: _______________________________________ HEALTH INSURANCE INFORMATION Does the patient have health insurance? ?Yes ?No If yes, please indicate type of insurance (check all that apply): ?Private insurance ?Medicaid ?Medicare ?Charity care ?VA program HOUSEHOLD FINANCIAL INFORMATION Is patient currently employed? ?Yes ?No Marital Status of head of household:____________________________Number of people in household: ______________________________ FAMILY INCOME SOURCES (please check all that apply): ?Social Security (retirement) ?Salary ?Pension ?Unemployment ?Public assistance ?Short-term disability ?SSD (Disability) ?SSI ?Family/friends provide support, Amount per month _______________?Other - specify ____________________________________________ TOTAL ANNUAL FAMILY INCOME $_________________________ FAMILY ASSETS (provide total amount in all accounts that apply): Checking/Money Market: $________________ Savings/CD: $____________ IRA/403B/401K: $________________ Stocks & Bonds: $_______________ TOTAL FAMILY ASSETS $______________________________________ MONTHLY EXPENSESPlease complete information for ALL monthly bills. Please list the average monthly amounts paid for the following items.Rent/Mortgage $_________ /mo. Has a late notice been received? YES NODo you pay association dues? (Homeowner Association)? YES NOIf so, how much are the dues? $ ________ Are they behind? YES NO ________ If so, what is the balance? $_________Is your home currently in foreclosure? YES NO I don’t knowIf so, what is the amount you are behind? $_________Avg. Electric $______ /mo. Has a late notice been received? ____ How much is owed? $______Avg. Water $ _______/mo. Has a late notice been received? ____ How much is owed? $______Avg. Propane/Natural Gas $______/mo. Has a late notice been received? ____ How much is owed? $______List the average monthly amounts paid for the following items: Child Care $ /mo.Car Payment $/mo. Car insurance $/mo. Home/Cell Phones $/mo.Cable/Satellite $/mo. Gas/Transportation $/mo.Food/Personal Items $/mo.Other monthly bills: $/mo Bill type:_______________________________________ $______/moBill type:_______________________________________ $______/moBill type:_______________________________________ $______/mo (Use additional sheets if necessary)FINANCIAL ASSISTANCE NEEDS (Check all that apply)I need help with the following cancer-related expenses: ?Transportation ?Child care ?Groceries ?Medical Bills/Prescriptions? Living expenses/Other (please describe)___________________________________________________________ANY ADDITIONAL INFORMATION?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________The information on this application is true to the best of my knowledge.Signature: ______________________________________ Date: ________________________________ THANK YOU. Please mail your COMPLETED form to: Heather Baker Foundation, c/o Linda Hartman, 678 Old Hanover Rd, Spring Grove PA 17362 The Heather Baker Foundation will review this information and contact the person requesting financial assistance. All information is strictly confidential and is for The Heather Baker Foundation internal use only. ................
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