Small Pearls of Hope
11661 Preston Rd #154
Dallas, Texas 75230
Phone: (214) 365-9165
Fax: (214) 692-8945
info@smallpearlsofhope.org
BREAST CANCER PATIENTS ONLY
Important Information
All awards are made at the sole discretion of the Small Pearls of Hope Panel. Each
application is given careful, individual consideration, but Small Pearls of Hope cannot
guarantee that all applicants will receive a commitment of assistance.
Please be advised that the review process of your application will take a minimum of up
to 30 days.
Failure to submit a complete application as well as the required documentation will result
in a delay in processing your application.
Please contact Small Pearls of Hope at any time if you have questions or would like
assistance completing the application.
Please submit a copy of your current Texas Driver's License or I.D. with an address
matching your application, and a copy of your last pay stub. If you do not have a Texas-
issued license or I.D., you can submit a rental contractor mortgage bill with your name on
it; if bills are in a spouse's name, include marriage license.
Biographical Information Date:__/__/__
Name: Date of Birth:
SSN:
Address:
City: State: Zip:
Home Phone: Work Phone: Cell Phone:
Preferred Method of Communication:
Do you live alone? Marital Status:
No. of Adults in Home:
No. of Children in Home: Ages of Children: Ethnicity: (optional))
Are you a U.S. Citizen? Birth? Naturalization?
If by Naturalization, please list Date, Certificate No. and Court
How did you hear about Small Pearls of Hope?
If you were referred by an individual or another Organization, please list the name of the
referring party:
What specific assistance are you seeking? (please check all that apply)
Rent/Mortgage (attach copy) Child Car Utilities
Car Loans Life Insurance Premiums
How many months do you foresee needing this requested assistance from Small Pearls of
Hope?
Is there anything else you would like to tell the Panel about yourself and your situation?
Financial Information
INCOME - HOUSEHOLD (Please enter monthly income from all sources):
Before Diagnosis After Diagnosis
Applicant Salary (gross/pre-tax)
Spouse/Significant Other Wages/Salary (gross/pre-tax)
SSI/SSD
Unemployment Insurance
Employer Disability Insurance
Alimony/Child Support Received
Section 8 from HUD (housing supplement)
Food Stamps
Aid from Other Nonprofit Organizations
Other
ASSETS
Cash/Checking Account
Savings Account
Other Bank Accounts
Real Estate (other than owner occupied)
Life Insurance
Investments
Other
TOTAL INCOME:
EXPENSES - HOUSEHOLD
Before Diagnosis After Diagnosis
Rent / Mortgage
Employment Taxes
Gas / Electric
Child Care
Water / Sewer / Garbage
Telephone
Car Payment
Gasoline
Auto Insurance
Entertainment (dining out/cable TV/internet service)
Child Support Obligation
Transportation (bus, train, taxi, parking)
Medical Costs - out of pocket
Medication costs - out of pocket
Health Insurance Premium
Credit Card Payments
Other : ____________________________________
TOTAL HOUSEHOLD EXPENSES:
Health Insurance: (Please check applicable box)
Private MediCaid Medicare Other None
Employment Status BEFORE diagnosis: (Please check applicable box)
Full Time Self Employed Unemployed Part Time On Leave
Employment Status AFTER diagnosis: (Please check applicable box)
Full Time Part Time On Leave Self Employed Unemployed
Current Diagnosis
Date Diagnosed: Stage: Type of Cancer:
Treatments currently in Progress:
Surgery: Date of Surgery:
Radiation: Chemotherapy: Other:
Date of First Treatment No. of Remaining Treatments
Are you being treated for a recurrence? YES NO
Please fill out the contact information (name, location, telephone #) for your medical
team below.
Surgeon
Oncologist
Radiation Oncologist
Social Worker / Case Manage
Hospital
I hereby affirm the following:
I reside in the State of Texas.
I am currently a breast cancer patient either recovering from a cancer-related
surgery or undergoing chemotherapy, radiation therapy, or gene therapy.
I qualify for temporary financial assistance from Small Pearls of Hope based on the
following criteria: (please check all that apply)
□ Total household income from all sources (including but not limited to wages,
retirement pension, alimony, worker's compensation, Social Security, employer disability
insurance, etc.) does not meet the sum of all financial obligations for the patient's
determined treatment period.
□ Household income during the treatment period has dropped or will drop more than
25% after the first month of treatment.
□ Total household income is too high to qualify for government aid but still does not
meet the sum of all financial obligations for the patient's determined treatment period.
□ Individual is receiving federal or state government aid (including but not limited to
SSI or SSDI), but cannot meet monthly financial obligations.
□ Due to the length and/or severity of the treatment, the Applicant will be unable to
work or contribute to the household income for a period of at least four (4) months.
□ By signing this document, I agree and or commit to attending four (4) support groups.
Small Pearls of Hope feels that this requirement will motivate and improve the livelihood
of those diagnosed with breast cancer by providing peer nourishment and informative
resourcing.
In addition to the above qualifying factors, I also hereby affirm the following:
□ I have no liquid assets, including, but not limited to stocks, bonds, mutual funds,
secondary real or personal property, other than funds in a 401K, IRA, or other retirement
fund.
□ I understand that even if I meet some or all of the qualifying factors above, any
financial assistance is ultimately at the discretion of the Small Pearls of Hope Board of
Directors.
I have signed the application which serves as a medical release, giving Small Pearls
of Hope permission to obtain the necessary medical information to process my
application.
I understand that Small Pearls of Hope provides services that are free and that all
awards are made at the sole discretion of the Panel. The information provided in
this application is true.
I release Small Pearls of Hope of all liabilities or claims whatsoever arising out of
the donation of money and/or services provided. I authorize Small Pearls of Hope to
release any information including my name, address, and type of assistance
provided to any other social service agency at its discretion. I also authorize the
release of any medical information and documentation required by Small Pearls of
Hope for the purpose of verifying this application and I agree to sign any additional
authorizations that may be required.
Applicant's Signature:
Applicant's Name: (printed))
Date:
HIPPA RELEASE
I, _______________, intend for any agent named in this release to be treated as I would
be treated with respect to my rights regarding the use and disclosure of my individually
identifiable health information and other medical records. This release authority applies
to any information governed by the Health Insurance Portability and Accountability Act
of 1996 ("HIPAA"), 42 U.S.C. 1320d and 45 C.F.R. 160-164.
I authorize the disclosure of any information governed by HIPAA to be provided to Traci
Byrd, or any other Panel Member of Small Pearls of Hope.
Accordingly, I hereby authorize any physician, health-care professional, health plan,
hospital, clinic, laboratory, pharmacy or other covered health-care provider, any
insurance company and the Medical Information Bureau Inc. or other health-care
clearinghouse that has provided treatment or services to me, or that has paid for or is
seeking payment from me for such services, to give, disclose and release to any agent
who is named herein and who is currently serving as such, without restriction, all of my
individually identifiable health information and medical records with respect to my breast
cancer diagnosis.
This authority given to any named agent shall supersede any prior agreement that I may
have made with my health-care providers to restrict access to or disclosure of my
individually identifiable health information. The individually identifiable health
information and other medical records given, disclosed, or released to any named agent
may be subject to disclosure by a named agent and may no longer be protected by
HIPAA. The authority given to any named agent herein has no expiration date and shall
expire only in the event that I revoke this HIPAA Release in writing and deliver it to my
health-care provider.
There are no exceptions to my right to revoke this HIPAA Release.
______________________________ ______________________
Patient Signature Date
SUBSCRIBED AND SWORN TO BEFORE ME by the said Patient listed
above, this day ________of ___________________, A.D. 200__.
__________________________________
Notary Public, State of TEXAS
PRIVACY NOTICE
Small Pearls of Hope ("The Organization”) and its staff, employees, Board of
Directors, and volunteers follow the privacy practices described in this Notice.
The Organization is required by law to maintain the privacy of your health information,
whether in paper or electronic records, and to protect the integrity, confidentiality, and
availability of your electronic health information when it is collected, maintained, used or
transmitted by or within the Organization.
The Organization must share your medical information, as necessary, with the Board
Members for acceptance into its assistance program. Your medical information also may
be used or disclosed, unless you ask for restrictions on a specific use or disclosure, for the
following purposes:
. To discuss with one or more of your family members the status of your application
for assistance or your ongoing assistance with the Organization;
· To verify diagnosis and/or treatment status with the Social Worker(s) listed on your
application;
· To verify diagnosis and/or treatment status with the physician(s) listed on your
application;
· To respond to any lawsuit, law enforcement investigation, or in response to a court
order or subpoena; or
· As otherwise required by law.
Except as authorized above, The Organization will not use or disclose your medical
information without your express written consent. You may revoke your permission at
anytime, effective only after the date the written revocation has been received by a
representative on The Organization's board.
You may request a change in the preferred method of communication, as selected on
page 1of your application, but you must specify in writing the requested change. This
change will only take effect upon written receipt of such request by a representative on
The Organization's board.
You may request a list of the disclosures of your medical information that have been
made to persons or entities since the acceptance of your application for assistance. After
the first request, there may be a charge.
You may request a copy of this Notice at any time.
The Organization is required by law to provide you with this Notice. It will be governed
by this Notice for as long as it is in effect. If The Organization changes this Notice at any
time in the future, you will be notified of the changes in writing.
If you believe your privacy rights have been violated, you may file a complaint with the
President of Small Pearls of Hope at the following address: 11661 Preston Rd #154
Dallas, Texas 75230, Phone: (214) 365-9165, Fax: (214) 692-8945.
To obtain further information about the federal privacy rules or to submit a complaint to
the Department of Health and Human Services, you may contact the Department by
telephone at (214) 767-4056, fax at (214) 767-0432, TDD at (214) 767-8940, electronic
mail at ocrocomplaint@hhs.gov, or by regular mail addressed to: Region IV, Office for
Civil Rights, U.S. Department of Heath and Human Services, 1301 Young Street, Suite
1169, Dallas, TX 75202.
You will not be penalized or retaliated against in any way for making a complaint to
Small Pearls of Hope or the Department of Health and Human Services.
Contact Small Pearls of Hope at: (214) 365-9165 if:
·You have a complaint;
·You have any questions about this Notice;
·You wish to request restrictions on uses and disclosures of health care
information; or,
·You wish to obtain a form to exercise any other right(s) described above in this
Notice.
By my signature below, I hereby affirm that I have received a copy of this Privacy Notice
from Small Pearls of Hope.
__________________________________________________
Signature of Applicant Date