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Document Sample
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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