"Currently we are only able to offer travel assistance to"
Application for Travel Assistance for Brain Tumor Patients in a Clinical Trial Currently we are only able to offer travel assistance to Brain Tumor Patients who are enrolled in a brain tumor clinical trial and need travel assistance in the U.S. to participate in that trial. Please provide us with the information requested below; understanding that the submission does not confirm your eligibility for any financial assistance and additional information may be needed in the future. Name of Patient:_______________________________________________________________________ Street Address: ________________________________________________________________________ City: ___________________________________ State: ____________________ Zip Code: _________ Home Phone: ____________________________ Work/Cell Phone: ______________________________ Date of Birth: ______________________________ Email: _____________________________________ Social Security Number (Required): ________-____________-_______ Diagnosis: ____________________________________________________________________________ Name of Employer: _________________________________________________ Phone: _____________ Financial Information: Please provide the following information about the monthly finances of the household applying for assistance. Include a copy of your most recent tax return, W-2 forms and any supporting schedules. Gross Income: $ ___________________ Utilities Exp: $ _______________________ Housing Exp: $ ____________________ Medical Travel Exp: $__________________ Groceries Exp: $ ___________________ Automotive Exp: $ ____________________ Medical Exp: $ _____________________ Debt Payments: $ ____________________ Other Exp: $ _____________________ (Please Explain) _____________________________________ _____________________________________________________________________________________ Any other information you would like to share with us that you think is important in determining your financial eligibility for flight assistance (use a separate sheet if necessary):_________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Miles For Hope, Inc. - www.MilesForHope.org Moving Towards a Cure - 727-647-6548 Tell us about your household. Include Name & Age (use additional sheet if needed) Spouse/Partner ______________________________________ _______ Living with you?:______ Child 1 _____________________________________________ _______ Living with you?:______ Child 2 _____________________________________________ _______ Living with you?:______ Child 3 _____________________________________________ _______ Living with you?:______ Name & address of Physician (performing Clinical Trial): _______________________________________ ___________________________________________________________ Phone: ___________________ Name of Oncologist: __________________________________________ Phone: ___________________ Name of Oncology Social Worker: _______________________________ Phone: ___________________ Hospital Affiliation: ___________________________________________ Phone: ___________________ Are you currently participating in a Clinical Trial for your Brain Tumor or have been approved for one? _____________________________________________________________________________________ If so, what is the name of the clinical trail? __________________________________________________ Physician conducting clinical trial (name, address, phone)?_____________________________________ ____________________________________________________________________________________ What is the anticipate date of your next appointment or start of clinical trial?______________________ At what facility is the clinical trail?_________________________________________________________ What is your expected airport/city of travel for the clinical trial? (ie Charlotte, NC to Los Angeles, UCLA)? _____________________________________________________________________________________ Miles For Hope, Inc. - www.MilesForHope.org Moving Towards a Cure - 727-647-6548 List any special travel consideration or needs that might be required or requested. (ie: Wheel chair, assistance at airport, etc):_______________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please provide us with any information you believe is important for us to know regarding your request for travel assistance (be sure to include travel date and location/hospital): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ How were you referred to Miles for Hope? __________________________________________________ Are you related to or do you know anyone associated with Miles for Hope? ________________________ Once completed, fax completed application, along with required information to: 727-796-0067 Miles For Hope, Inc. - www.MilesForHope.org Moving Towards a Cure - 727-647-6548 Authorization for Release of Information To ensure the continuity of my medical care I hereby authorize Miles for Hope and its representatives to discuss my Application for Financial Assistance, (including but not limited to my financial information, diagnosis and treatment) and related medical care with my physicians, medical representatives and financial advisors, as needed. I also authorize the release, as needed, of any medical records and information by my medical providers to Miles for Hope. _________________________________ ________________________________ Patient/Legal Guardian Witness _________________________________ ________________________________ Print Name Print Name _________________________________ ________________________________ Date Date ______________________________ ________________________________ Miles or Hope Representative Date Reviewed Once completed, fax completed application, along with required information to: 727-796-0067 Miles For Hope, Inc. - www.MilesForHope.org Moving Towards a Cure - 727-647-6548 Waiver and Release In consideration of my acceptance of financial aid or benefits from Miles for Hope, I hereby, for myself, my heirs, my executors and administrators, waive any and all claims I may have against Miles for Hope, Inc., its employees, agents, representatives, assigns, and anyone else working with them, as well as all participating groups and any other individuals associated with Miles for Hope, their representatives, successors and assigns, and hereby agree to hold harmless Miles for Hope, Inc. as well as all of these individuals and groups for any and all injuries and/or damages that may be sustained by me in any manner arising out of or in connection with Miles for Hope. In addition to the foregoing, and in further consideration of my acceptance of financial aid or benefits from Miles for Hope, I hereby grant my permission to Miles or Hope, Inc. to use my image and any photos, motion pictures, recordings, or any other form of record for this event for any legitimate purpose. Furthermore, I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback. In filling out this form I acknowledge I have read and fully understand the terms of this Waiver and Release and expressly agree to all such terms without reservation. Date:_____________________________________ Signed:___________________________________ Print Name:________________________________ Once completed, fax completed application, along with required information to: 727-796-0067 Miles For Hope, Inc. - www.MilesForHope.org Moving Towards a Cure - 727-647-6548