Treatment Support Grant Application

Application for Financial Assistance
Only completed application packets will be accepted.
Section 1: Patient Information
Applicant's Name:*
First Middle Last
Address*
Street Address Apt / Suite City State ZIP Code
Contact Phone 1:*
Contact Phone 2:
Email:*
Date of Birth:*
MM slash DD slash YYYY
Marital Status:*
Last 4 Numbers of Social Security Number:*
Who Referred you to Hooked on Hope?
Source of Income & General Information
Primary Source of Income:*
Employed:*
- Yes
- No
Do you have sick time, vacation time, or short/long-term insurance available?*
- Yes
- No
Have you lost, or will you lose income because of undergoing breast cancer treatment?*
- Yes
- No
Please explain (i.e. taking unpaid time off from work to undergo treatment, on FMLA/unpaid medical leave, self-employed):*
Will you be returning to work?*
- Yes
- No
When will you be returning to work?*
MM slash DD slash YYYY
Health Insurance
Are you covered by Health Insurance?*
- Yes
- No
Type of Health Insurance:*
- Commercial through Employer
- Marketplace (ACA)
- Medicaid
- Medicare
Breast Cancer Treatment
Date your Breast Cancer Treatment began:*
MM slash DD slash YYYY
Date your Breast Cancer Treatment ended:
MM slash DD slash YYYY
Treating Physician(s):*
Section 2: Financial Information
Number of adults living in your household:*
Please enter a number from 0 to 10.
Number of children (Under 18) living in your household:*
Please enter a number from 0 to 10.
Household Monthly Income
Please enter all that apply and upload copies of documentation. You MUST Report Income for ALL Members of Your Household!
Employment Wages (NET Income after Taxes)*
Social Security (retirement)*
SSI / SSDI (Disability)*
Pension / Retirement*
Unemployment*
Short Term Disability / Sick Leave*
Alimony or Childcare*
Other Income*
Hidden
Monthly Income Total:
Household Monthly Expenses
Fill in the amount of each monthly bill. Copies of bills for which financial assistance is requested, must be uploaded.
Rent / Mortgage*
Phone(s)*
Electric / Gas*
Water / Sewer*
Food*
Auto Payment*
Auto Fuel*
Auto Insurance*
Property Insurance*
Property Tax*
Life Insurance*
Health Insurance*
Alimony*
Child Support*
Co-Pays for Office or Treatment Visits (for breast cancer treatment)*
Prescriptions (for breast cancer treatment)*
Other Expenses*
Hidden
Monthly Expenses Total:
Household Assets
Please enter all that apply.
Amount in Checking Account*
Amount in Savings or Money Market*
Cash On Hand*
Value of 401K, Retirement Funds, Stocks, Bonds, etc.*
Hidden
Assets Total:
Do you or your spouse/partner own property other that your Primary Residence?*
- Yes
- No
Do you or your spouse/partner/family own a business?*
- Yes
- No
Additional Information
Is there any other information you wish to share with the Grants Committee?
Important Notifications
[1] Application must be completed in its entirety, to include upload of required documentation. [2] Documentation must be properly uploaded once. Documents will not be received ‘piece meal.’ [3] Incomplete applications will NOT make their way to Grants Committee for review. [4] Grants Committee Members are confidential. [5] Must allow up to thirty (30) days for application review. Payments may take up to 30 days to process. [6] Applications will be reviewed without bias based on age, race, county of residence, or treating physician(s). [7] The basis of determination by the Grants Committee will be available, in writing, upon request. [8] Applications will remain open for no greater than thirty (30) days from date of receipt.
Release and Terms Of Agreement
I certify that all the information I have provided is true, complete and correct. I expressly authorize, without reservation, the Hooked on Hope Breast Cancer Treatment Support Grants Program and its advisors or representatives to contact and obtain information in order to verify the accuracy of information provided by me in this application. I understand that I will be required to provide backup documentation to Hooked on Hope or its representatives in order to verify the information provided herein. I understand that any information that may not be verified, is incomplete, or is misrepresented in any respect will be sufficient cause to eliminate me from consideration for financial assistance and will result in the denial of this application. Do not sign until you have read the above application statement. I certify that I have read, fully understand and accept all terms of the foregoing application statement: I understand that my application may not be submitted to the Hooked on Hope Grants Committee for consideration unless it is completed in its entirety and required/requested backup documentation has been provided.
Electronic Signature:*

Please enter full legal name.
Date*
MM slash DD slash YYYY
Consent*
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms Of Acceptance..
Supporting Documentation
Please upload supporting documentation for Proof of Treatment & Section 2: Financial Information.
File*
Drop files here or

Max. file size: 100 MB.

Treatment Support Grant Application

Application for Financial Assistance

Section 1: Patient Information

Source of Income & General Information

Health Insurance

Breast Cancer Treatment

Section 2: Financial Information

Household Monthly Income

Household Monthly Expenses

Household Assets

Additional Information

Important Notifications

Release and Terms Of Agreement

Supporting Documentation