Download the application form by Massachusetts

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									The Catastrophic Illness
             In Children Relief Fund
                                                   When other resources end, we begin.
                            REQUEST FOR FINANCIAL ASSISTANCE

REFERRAL SOURCE

 DPH web site                                                Dept of Public Health Care                Community Case Mgmt
 Health Care Provider (doctor, nurse, etc)                    Coordinator                               Autism Support Center
 Hospital Social Worker                                      DPH Community Resource Line               Pediatric Palliative Care
 Home Health Services / VNA                                  Family TIES Program of MA                  Network
 Dept of Mental Retardation Case Manager                     MA Commission for the Blind               Word of Mouth (friend,
  or Contracted Agency/Vendor                                 MA Rehabilitation Commission              neighbor, co-worker etc.)
 Dept of Mental Health                                       Early Intervention                        Other (specify)
                                                                                                        ________________________
                                                                                                        ________________________


CHILD INFORMATION
Name (First, Middle, Last)                                             Street Address


City/State/Zip                                                                             Home Telephone


Date of Birth                                        Sex                                   Primary Language
                                                      Male              Female

Race:      Caucasian         Asian        African-American          Hispanic         Other ___________________________


FAMILY INFORMATION
Parent/Guardian #1                                                     Parent/Guardian #2
Name (First, Middle, Last)                                             Name (First, Middle, Last)

Relationship to Child                                                  Relationship to Child

Home Address                                                           Home Address



Mailing Address (if different)                                         Mailing Address (if different)



Home Telephone                                                         Home Telephone

Work Telephone                                                         Work Telephone

E-mail                                                                 E-mail

Primary Language                                                       Primary Language



Catastrophic Illness in Children Relief Fund – Application – Revised 1/08                                          (Page 1 of 6)
List all family members who live in the child’s household. Include the child’s parent(s)/guardian(s) who
live with the child and any brothers or sisters who live with the child.
      Name of Family Member                              Date of Birth                 Relationship to Child
       (first name, last name)                         (month / day / year)




HOUSEHOLD TYPE (select one):                              Single-parent/guardian     Two-parent/guardian


HEALTH INSURANCE INFORMATION

List all health insurance policies that cover child. If child is uninsured, write “none.”
HMO/Insurance Company                               Policy Holder Name                 If MassHealth, specify type:
Primary Insurance Company:                                                                 MassHealth Standard
                                                                                           MassHealth Limited
                                                                                           CommonHealth
Secondary Insurance Company:                                                               MassHealth Standard
                                                                                           MassHealth Limited
                                                                                           CommonHealth

CHILD’S MEDICAL INFORMATION

Primary Diagnosis: __________________________________________________________________________
Secondary Diagnosis: ________________________________________________________________________

Briefly describe child’s condition and proposed treatment plan, including whether the child is currently
hospitalized or at home: (Attach a separate sheet if necessary.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

     Provider                      Name                    Facility/Address         Phone         Hospital Affiliation, if any
Primary Care
Doctor

Current Treating
Doctor (if
different)
Social Worker or
Case Manager

Department of
Public Health
Care Coordinator




Catastrophic Illness in Children Relief Fund – Application – Revised 1/08                                  (Page 2 of 6)
                                                      ~ IMPORTANT!! ~
    Only expenses for which the family is directly responsible as a result of the treatment, habilitation or
     rehabilitation of a child’s illness or medical condition may be considered for reimbursement. Expenses
     covered by health insurance or other sources are not eligible in the calculation of total eligible expenses.
    Please note that the Catastrophic Illness in Children Relief Fund will only consider expenses incurred within
     the past two years of the date the application is received.

EXPENSE INFORMATION
List the expenses for which financial assistance is being requested in the appropriate category.
                         Expense Category                                    Amount of Expense        Date(s) of Service
Ambulance (ground or air ambulance)
Ancillary Services (eg. therapies)
Child Care (for siblings, while child is receiving medical care)
Family Support (expenses, while child is hospitalized)
Funeral Expenses (eg. services, burial plot)
CommonHealth, MassHealth, and CMSP Premiums
Home Health Care (Nursing, PCA)
Home Modification – Exterior
Home Modification – Interior
Hospital, In-State
Hospital, Out-of-State
Laboratory, In-State
Laboratory, Out-of-State
Lodging (hotel expenses)
Medical Equipment and Supplies (eg. generators)
Medication
Mobility Equipment (eg. stairlifts)
Physician, In-State
Physician, Out-of-State
Vehicle Modification
Vehicle Purchase
Other:
Other:

Which organization(s) have you already applied to for assistance? (financial or other) (Check all
that apply)
 Department of Mental Retardation                      Department of Public Health Care       Private Agencies
 Department of Mental Health                            Coordinator                            Grants
 MA Commission for the Blind                           Early Intervention                     Public Fund Raising
 MA Commission for the Deaf and Hard                   MSCPA (HIPP)                           Other (specify)
  of Hearing                                            Kaileigh Mulligan                       _______________________
 MA Rehabilitation Commission                          MASSTART
 DMR Autism Division                                   Pediatric Palliative Care Network



Catastrophic Illness in Children Relief Fund – Application – Revised 1/08                                (Page 3 of 6)
Explain why assistance is being requested from the Catastrophic Illness in Children Relief Fund
to pay for your child’s medically related expenses. If coverage of services have been denied by your
child’s insurance company or MassHealth, attach any written documentation you have received of the
denial.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

FAMILY FINANCIAL INFORMATION
List all income you receive. List gross income (before taxes and deductions) for each family member
who receives other income.

      Type of Income              Name(s) of Family                  Amount            How Often            CICRF Use Only
                                 Member(s) Receiving                 Received         (Circle one)           Annual Income
                                      Income
Employment                                                                      Weekly, Monthly, Annually
Employer:
__________________
Employment                                                                      Weekly, Monthly, Annually
Employer:
__________________
Alimony                                                                         Weekly, Monthly, Annually

Annuities / Insurance                                                           Weekly, Monthly, Annually

Child Support                                                                   Weekly, Monthly, Annually

Dividends                                                                       Weekly, Monthly, Annually

EAEDC                                                                           Weekly, Monthly, Annually

Interest                                                                        Weekly, Monthly, Annually

Money from absent family                                                        Weekly, Monthly, Annually
member
Pension / Retirement                                                            Weekly, Monthly, Annually

Rent / Royalties                                                                Weekly, Monthly, Annually

Social Security                                                                 Weekly, Monthly, Annually

SSI                                                                             Weekly, Monthly, Annually

TAFDC                                                                           Weekly, Monthly, Annually

Trust / Estates                                                                 Weekly, Monthly, Annually

Unemployment                                                                    Weekly, Monthly, Annually

Veterans’ Benefits                                                              Weekly, Monthly, Annually

Workers’ Comp.                                                                  Weekly, Monthly, Annually

Other Income (specify)                                                          Weekly, Monthly, Annually




Catastrophic Illness in Children Relief Fund – Application – Revised 1/08                                   (Page 4 of 6)
                           STATEMENT OF UNDERSTANDING AND SIGNATURES


I understand that the information in this application will be used by the Catastrophic Illness in Children
Relief Fund Commission and associated staff of the Massachusetts Department of Public Health (DPH)
for the purposes of determining eligibility for financial assistance from the Fund. I understand that the
Commission makes the final determination of eligibility and the amount of award for payment or
reimbursement. Since the amount in the Fund and the number of requests for assistance varies from
year to year, I understand that I should not assume or make financial decisions based on an expectation
that the Fund will pay.

I give permission to Commission members and associated DPH staff to contact any other state agency,
employer, medical provider, insurer, or any other contact listed on this form to verify information and/or
to collect further information relevant to this application for the purpose of determining eligibility and
amount of the award. I also understand that the information I have provided to the Commission may be
shared with other state human service agencies for such purposes as coordinating services, determining
eligibility for other programs, and finding ways to pay for medical and other expenses.

I understand that I may cancel this consent at any time by providing the Catastrophic Illness in Children
Relief Fund with a signed, dated letter stating that I wish to withdraw the Fund’s authorization. Without
a letter stating that I wish to withdraw consent, the Catastrophic Illness in Children Relief Fund’s
authorization will continue for 18 months from the date signed.

I HEREBY SWEAR, UNDER THE PAINS AND PENALTIES OF PERJURY, THAT THE
INFORMATION I HAVE PROVIDED IN THIS APPLICATION IS ACCURATE AND COMPLETE,
TO THE BEST OF MY KNOWLEDGE.

Parent/Guardian #1:                                                    Parent/Guardian #2:

_________________________________                                      _________________________________
Signature                                                              Signature
_________________________________                                      _________________________________
Print Full Name                                                        Print Full Name
_________________________________                                      _________________________________
Date                                                                   Date


                                       FOR APPLICANTS AGE 18 OR OLDER:*

I have read and understand the information above. I give permission to Commission members and DPH
staff working with the Commission to receive and share information in the ways described above. I also
give them permission to share information about me with my parents, and to receive information from
my parents as needed to determine eligibility and the amount of assistance.


_____________________________                          _____________________________           ______________
Signature of applicant age 18 or older                 Print Full Name                         Date


* A signature is required of all applicants age 18 or older unless they have a court-appointed guardian, in
which case documentation of guardianship must be provided.

Catastrophic Illness in Children Relief Fund – Application – Revised 1/08                           (Page 5 of 6)
                                     SUBMIT COMPLETED APPLICATION TO:

                                     Catastrophic Illness in Children Relief Fund
                                          MA Department of Public Health
                           Division for Perinatal, Early Childhood & Special Health Needs
                                           250 Washington Street, 5th Floor
                                               Boston, MA 02108-4619



Please contact the Catastrophic Illness in Children Relief Fund staff if you have any questions or would
    like help completing this application. Fund staff may be reached by calling: 1-800-882-1435.




Catastrophic Illness in Children Relief Fund – Application – Revised 1/08                   (Page 6 of 6)

								
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