322 Nancy Lynn Lane Suite# 3 Knoxville, TN. 37919: www.AmericanCancerSupport.org P. (865)-240-3116 F. (865) - 240 -3183 The Official Application Information and Instructions Dear Cancer Patient and Family, American Association for Cancer Support, Inc. is a dedicated cancer nonprofit organization. One of our programs, Cancer Patient Support Program, is designed to support cancer patients with available funds or supplies. Cancer is a dreadful disease that affects those suffering from it physically and emotionally. It is our goal to help relieve the patients and families’ hardships. To complete the application process, cancer patient will need to fill out the application form and the diagnosis verification form that must be signed by a medical professional and mail the form to: Patient Service Department 322 Nancy Lynn Lane Suite# 3 Knoxville, TN. 37919 or send email attachment to: [email protected]. Once we have received the completed forms, we will process and verify the information in the forms. Then, our Service Support Department will start to prepare your “Cancer Care Package” or “Cancer Care (visa) Card” depends on availability. God Bless, Patient Support Services American Association for Cancer Support, Inc. 322 Nancy Lynn Lane Suite 3 • Knoxville, TN 37919 Phone: 865 240 3116 E-mail: [email protected] APPLICATION FOR ASSISTANCE PATIENT INFORMATION FORM Patient’s First name: Middle: Last name: Birth date: ____/_____/_____ Age: Sex: □ M Home address: City: Phone No.: State: ZIP code: *Signature: E-mail: How did you hear about our program? □ Family □Friend How many people are in your household? □F □Callers □Other (specify): Estimated annual household income: *Under penalty of perjury, I declare that I have examined this form, including any accompanying statements and schedules, to the best of my knowledge; it is true, correct, and complete. VERIFICATION FORM THIS PORTION MUST BE COMPLETED BY A MEDICAL PROFESSIONAL ONLY Medical Professional: Title: Office address: City: Phone No.: EIN/FEIN: On remission?: Active treatment: □ Yes □ No Verification of Cancer Patient: ____________________________ Medical Professional Signature* State: ZIP code: Cancer type and stage: When is the next appointment: __________________________ Date (MM/DD/YYYY) *Under penalty of perjury, I declare that I have examined this form, including any accompanying statements and schedules, to the best of my knowledge; it is true, correct, and complete. Comments: EMERGENCY CONTACT PERSON OR GUARDIAN (OPTIONAL) Contact Name (first, last): Relationship to patient: X ___________________________ Contact Signature Home phone: ( ) Work phone: ( ) _________________________ Date (MM/DD/YYYY) For more information, please visit our website @ AmericanCancerSupport.org Join our community by LIKE US on APP-2015 MEMORANDUM OF UNDERSTANDING This MEMORANDUM OF UNDERTANDING is entered between AMERICAN ASSOCIATION FOR CANCER SUPPORT, INC. (hereinafter “AACS”), located at 322 Nancy Lynn Lane Suite# 3 Knoxville, TN. 37919 and PATIENT: Name Last name , whose address is PARTIES 1. 2. AACS is a nonprofit tax exempt organization described in Section 501(c)(3) of the Internal Revenue Code. The primary purposes for which AACS was formed is to support cancer patients and their families through its distribution program to distribute assistance funds and commodities; to advocate healthy eating and provide educational initiatives for cancer awareness prevention. PATIENT: name last name is a natural person. RECITALS 3. 4. AACS, as one of its charitable programs, provides support to cancer patients and their families through its relief funding programs. Name: is a cancer patient. TERMS OF AGREEMENT Now, therefore, in consideration of the foregoing and mutual promises and covenants contained herein, the parties agree as follows: 5. 6. 7. 8. 9. AACS, at its discretion, agrees to provide PATIENT with assistance for the purposes of supporting cancer patients and their families. AACS agrees to provide the PATIENT with funds or supplies and PATIENT agrees to use these funds or supplies specifically to support a cancer patient and/or his/her family. PATIENT agrees to provide to AACS a narrative description of how this contribution, as well as any additional assistance provided by AACS, was used, at any reasonable request made by AACS. PATIENT agrees to provide AACS permission to use his/her information, including pictures and testimonials, for verification or any other purposes at AACS’s discretion. PATIENT agrees that any changes in treatment status will be reported to AACS. PATIENT understand that when cancer is in remission this means the end of the services. VERIFICATION I declare under penalty of perjury subject to all applicable laws that I have carefully reviewed the MEMO OF UNDERSTANDING and verified that that all the information provided is true and correct to the best of my knowledge. X ___________________________ Patient/Guardian Signature _________________________ Date (MM/DD/YYYY)
© Copyright 2024