Adam Adam Chambers Foundation

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					               Adam T. Chambers

                    Foundation, Inc.

                             Application for

                          Financial Assistance

The Adam T. Chambers Foundation can provide financial assistance
due to fundraisers and generous donations in our community. It is important that
funds be available for families experiencing the greatest
financial need. The Adam T. Chambers Foundation may be able to
help with your financial needs connected to your child’s Crohn’s disease or other
related I B D (Inflammatory Bowel Disease)

    Information about The Adam T. Chambers Foundation, Inc. is available at

                      The Adam T. Chambers Foundation
                      Guidelines for Financial Assistance

                       General Guidelines for Assistance

1. Any child diagnosed with Crohn’s or other related I B D (inflammatory Bowel Disease) on or
   before their 21st birthday is eligible for consideration.

2. Children must be citizens or lawful, permanent residents of the U.S. who have
   Maintained uninterrupted residency for 12 months. Non-citizen residents must
   Provide ATCF with a photocopy (front and back) of their 1551 card (green card).

3. All sections of the application must be completed thoroughly and accurately in order
   for the ATCF to review the request. Failure to provide complete and truthful information is basis for

4. In order to review the request for financial assistance, a hospital professional
   (Doctor, nurse or social worker) MUST SEND A LETTER OF SUPPORT.
   This mat be sent via facsimile, email or postal service and should include the
        Child’s full name, date of birth and diagnosis
        Past treatment information
        Treatment plan for the next 60 days
        Type of assistance requested
        Other community resources being utilized

5. Financial assistance is provided for a maximum of 90 calendar days and up to
   $ 1000 for approved applications. After this period, additional letters of request from the hospital
   professional may be submitted to the ATCF if further assistance is needed.

6. Request cannot be processed until all information is received. ATCF will only send
   monies directly to the treatment provider or third party vendor. (Monies for gas, tolls, food, etc. will
   be issued only upon receipt of proper documentation. Attached form filled out and initialed by
   hospital professional).

   After you complete the application, please forward it to The Adam T. Chambers
   Foundation Inc..
   This may be mailed or faxed to: The Adam T. Chambers Foundation
                                       P.O. Box 1434
                                       Princeton, WV.24740
                                       Or Fax 304-425-6653

                                                                            OFFICE USE ONLY
                                                                               Date Received_____________

             PERSONAL INFORMATION- Please PRINT and complete all sections accurately

Patient Name (First, middle, last)____________________________________ ___Male ___ Female
Date of birth____________________________ Place of Birth (state/country)____________________
Social Security Number _________________________________________________________________
Parents’ / Guardians’ Names _____________________________________________________________
Does Guardian Speak English ___Yes ___ No If No, Primary Language?_______________________
Permanent Address _____________________________________________________________________
City / State/ Zip _______________________________________ Email address_____________________
Permanent Phone#_________________________ Cell Phone#__________________________________
Temporary Address (Name of Facility) _____________________________________________________
Address _______________________________________________________________________________
City/ State/ Zip _________________________________________ Temp Phone# ___________________
How did you hear about The Adam T. Chambers Foundation? __ Hospital Professional __Friend __
Emergency Contact Name __________________ Relationship ________ Phone #_________________

MEDICAL INFORMATION – This section to be completed by hospital personnel
                                (social worker, nurse, doctor)

A letter from a social worker, nurse, or doctor explaining the child’s diagnosis, family situation, and the assistance requeste
needed in addition o the completion of this section See guidelines for necessary

Name of Hospital _________________________________ Main Hospital # (____) _________________
Social Worker ( First and Last name) _______________________ Phone # (____) _________________
Pager # (____)______________________________ Email _____________________________________
Mailing Address__________________________________________Dept.__________________________
City/State/ Zip _________________________________________________________________________
Name of Physician (First and Last) ___________________________ Phone# (___)_________________
Diagnosis __________________________________________ Date of Diagnosis ___________________
Other treatment facility involved in child’s care _____________________________________________
Social Worker (First and Last Name) _________________________Phone # (___) _________________
Address__________________________________________________Dept _________________________
City/State/Zip __________________________________________________________________________

                                                            Patient Name__________________________

                                Insurance Information

Is the patient covered by private insurance? ___Yes ___No
Is patient covered by a state funded insurance plan? (i.e. Medicaid) __Yes __No
What is the name of the plan? _________________________________________
Policy Number _________________________ What is the percentage of coverage? ____
Address of Insurance Company _______________________________________________
City/State/Zip ____________________________________ Phone # (___) ______________
Does insurance provide assistance with meals, transportation, or lodging expenses?
______Yes _____No
Is there secondary Insurance? ____Yes ____No
If yes, what is the name of the Plan? ___________________________________________
If child does not have health insurance, has the family completed an application?
For Medicaid? ____Yes ____No

                                            Patient Name ___________________

 Request for Assistance with Supplemental Family Support

An Applicant may be eligible for supplemental family support for a child with Crohn’s
disease or other related IBD (Inflammatory Bowel Disease) for
Expenses related to treatment.
Supplemental family support includes food, travel, lodging, and medication.

Please check all that apply:

___________ Meals: ATCF will consider payment or reimbursement for meals for
parents and dependant family members.
___________ Transportation: ATCF will consider payment or reimbursement for
transportation expenses to and from treatment.
           Please state round trip mileage ______________

___________ ATCF will pay for lodging during treatment

___________ ATCF will consider payment or reimbursement for child’s medication
prescribed by hospital professional for the treatment of Crohn’s or other related
IBD (Inflammatory Bowel Disease).

                               Additional Request

Assistance may be requested for up to 3 months or 90 calendar days.
At the end of this time if additional assistance is needed, consideration will be given
to those request submitted in writing by a hospital professional. A new application is
only necessary when the length of time between requests exceeds one year.

                          Important Notice___ Please Read:

    The Adam T. Chambers Foundation, Inc. is a charitable organization dependent upon the
    public for support. These guidelines are a statement of the ATCF’s general policy, and
    the ATCF reserves the right, in its sole discretion, to modify the same at any time without
    prior notice. The ATCF tries to maximize the limited resources it has available.

    Patient Name: _________________________________________________

Approved applicants will be required to sign the enclosed statement by THE ADAM T.
CHAMBERS FOUNDATION, INC. affirming the use of funds that are approved.

    The ATCF will pursue restitution for funds approved if it is determined that the
    information submitted is false.

    I have read the Guidelines for Financial Assistance and I declare that the information
    furnished on this application, including attached sheets, is true and correct to the best of
    my knowledge.

    ______________________ ______                  ___________________         ______
    Signature of Mother/Guardian Date              Signature of Father/Guardian Date

    You will not be discriminated against or denied aid because of your race, religion, color,
    national origin, sex or political affiliation.

    All financial applications will be reviewed on a case by case basis and final determination
    will be made based upon the availability of funds.

    The ATCF reserves the right to deviate from the Guidelines when special needs arise.

    All information disclosed on this form is and will be confidential.


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