WAWELA Cancer support

Assistance application

Todays Date * +

Marital Status: *

Children *

Child's Ages

Applicants First Name *

Applicants Last Name *

Adult or Child ( please check one) *

Adult

Child

Date of Birth * +

Age *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address

Month & Year of diagnosis * +

Primary treating Physicians information:

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address

Current Medical Condition *

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Income *

Current Source of income: *

This applications was completed by *

Patient

Social Worker (signature of both patient and social worker is required)

Care Giver

Parent

First Name *

Last Name *

Contact Number *

Social Workers Signature required ( otherwise put N/A in the signature space below) *

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Patient Signature authorizing Social Worker/Care giver to submit on his/or behalf (this is a required field ( otherwise put N/A in the signature space below) *

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All applications will be processed in a timely manner. Assistance will be provided based upon verification, approval and available funds.

Medical Information Authorization: MINORS AGE UNDER 18: A legal guardian signature is required in order to release medical information regarding the documented condition. I hereby consent to the release of the specified information relating to diagnosis, testing or treatment to the person or entity named above. I understand that such information cannot be released without my informed consent. I acknowledge I have fully reviewed and understand the contents of this authorization form. My signature below indicates that I hereby agree to and authorize the release of patient health information to the above named person or organization. You have the right to revoke or cancel this authorization, in writing, at any time.

Signature Required: Acknowledge this form by using the pointer on your mouse to sign.

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