1

APPLICATION CHECKLIST

Name of Applicant: ________________________________________Phone Number: ___________________

All of the following items must be included in your application package. If they are not, processing may be delayed.

Please check off each item enclosed and include this sheet in your package.

Check Document or Description

Completed application with all forms

o Financial Worksheet (p. 3)

o Applicant Attestation (p. 4)

o Authorization of Disclosure of Protected Health Information (p. 5)

A signed letter, health records or verbal confirmation from a medical professional confirming diagnosis and treatment plan

First 3 pages of your tax returns from the previous year*

Completed NCCN Distress Thermometer (p. 6)

Completed COST Survey (p. 7)

Copies of billing statements for basic living expenses and/or health insurance premiums (with breakdown for multiple policy members) you wish to be considered for payment.

*If last year’s return is not available, submit the return from the previous year. If married and filed separately, submit all returns. If tax return is not filed, submit all W-2s and 1099 forms from the previous year. SSI award letter also accepted if other documentation not available. If tax return not filed, please attest below.

APPLICANT’S SIGNATURE: _____________________________________________ DATE: ________________

MAIL, FAX, or EMAIL YOUR COMPLETED APPLICATION and all required documents to:

Gateway to Hope 425 N. New Ballas Rd Suite 220 Creve Coeur, MO 63141 Or Fax: 314-432-3303 Or Email: info@gthstl.org

*Individuals residing in the southwest region of Missouri covered by the Breast Cancer Foundation of the Ozarks (BCFO) will be directed to BCFO for assistance with basic living expenses and will only be eligible for insurance premiums assistance through Gateway to Hope. Please visit http://www.bcfo.org/ for more information.

Check if applicable: I attest that I have not filed taxes for the last 2 years.

Check here if you would be willing to share your story with others, if asked in the future.

2

GATEWAY TO HOPE PROGRAM APPLICATION

NAME: ________________________________ DATE OF BIRTH: ___________________________ MARITAL STATUS: _________________________ RACE/ETHNICITY: _________________________ STREET ADDRESS: _________________________ CITY: _________________________________ STATE: ______________ZIP:________________

COUNTY: _____________________________

TODAY’S DATE: __________________________ PHONE: ______________________________ EMAIL: _______________________________ OCCUPATION: __________________________

EMPLOYER: ____________________________ HEALTH INSURANCE PROVIDER: ______________ # PERSONS COVERED: ______________________

TREATMENT INFORMATION

DIAGNOSIS:________________________ STAGE: _______________ (ER + / - ) ( PR + / - ) (HER2 + / - ) (PLEASE CIRCLE )

BIOPSY DATE: ___________ BREAST: (LEFT/RIGHT/BOTH) FACILITY: ___________________________________________

SURGERY: PHYSICIAN: ___________________ FACILITY: ___________________

PROCEDURE: PLEASE CIRCLE (LUMPECTOMY OR MASTECTOMY) (LEFT/RIGHT/BILATERAL) DATE: ________________

ONCOLOGY (CHEMOTHERAPY): PHYSICIAN: _______________________________ FACILITY: ____________________________

TREATMENT PLAN: __________________________________________________________________________________

_______________________________________________________________________________________________

NEO-ADJUVANT (BEFORE SURGERY) START DATE: ________________DATE COMPLETED: ______________

ADJUVANT (AFTER SURGERY) START DATE: ____________________DATE COMPLETED: _____________

RADIATION ONCOLOGY: PHYSICIAN: ______________________________FACILITY:___________________________________

# OF TREATMENTS PLANNED: __________ START DATE: ______________ DATE COMPLETED: ________________

REFERRAL SOURCE:

NAME: ____________________________TITLE (IF APPLICABLE): _________________FACILITY (IF APPLICABLE) _______________

SOCIAL WORKER/CASE WORKER/NURSE NAVIGATOR (OPTIONAL):

NAME: ____________________________PHONE #: ___________________ FACILITY: ___________________________

APPLICANT’S SIGNATURE: ____________________________________________________ DATE: _________________

3

Financial Worksheet

Complete financial information is required on all household members. Number in Household ___________

Household Assets Monthly Household Expenses

Checking Account. $ Rent Mortgage $

Savings Account $ Phone(s) $

Retirement Assets (e.g. 401k, IRA) $ Utilities $

Stocks & Bonds $ Transportation

Auto Payment(s) $

Monthly Household Income Auto Insurance $

Gross Monthly Wages $ Medical Expenses

Spouse’s Monthly Income $ Monthly Health Insurance Premium $

Additional Household Income $ Misc. (Specify) $ _____

Child Support $ Misc. (Specify) $

Alimony $

Food Stamps $

SSI/SSD benefit $

Veterans benefits $

Other (Specify) $

Total Monthly Income $

Stated Need

Please state need based on the following categories of assistance: health insurance premiums, rent/mortgage, basic

utilities (electric, gas, water, sewer, waste management), telephone, internet, car insurance, car payment, and car repair.

*Bill must be in applicant’s or spouse’s name. Not all bills may be eligible for assistance. Applicants in BCFO territory

(southwest MO) only eligible for health insurance premium assistance.

Expense Amount

Example: electric bill $150

1. __________________ _____________________

2. __________________ _____________________

3. __________________ _____________________

4. __________________ _____________________

5. __________________ _____________________

4

Applicant Attestation

In consideration for acceptance into the Gateway to Hope Program, I agree and certify as follows:

1. I attest that the information provided in this application is complete and accurate to the best of my

knowledge.

2. I understand that while every effort will be made to provide assistance, the Program is limited to the

availability of funds and I may not receive assistance even if I satisfy the eligibility requirements and

the other terms and conditions in the Program Guidelines.

3. I understand the Program Guidelines and eligibility criteria could be modified at any time and the

Program could be discontinued at any time.

4. I understand that GTH has the right to audit my eligibility and the accuracy of any documents or

information I provide and to request that I provide any additional information. I understand that if I apply

to receive assistance beyond the original grant term, I will be required to submit updated information to

GTH.

5. I understand that GTH will have the right to terminate any assistance granted if GTH becomes aware that

any information provided in this application is not accurate, if I do not provide any information requested

by GTH or if I do not meet the eligibility requirements and other terms and conditions set forth in the

Program Guidelines.

6. I will promptly notify GTH of any changes to the information I have provided to GTH, including

financial situation, health insurance status, or medical condition.

7. I understand that I am not required to use any particular health care provider as a condition of receiving

assistance under the Program and I am free to change my health care providers at any time.

8. I acknowledge that GTH may disclose certain information from my application to my health insurance

carrier, breast cancer caregivers, pharmacists, or other parties to fulfill my grant request.

9. I understand that from time to time, GTH aggregates data from many patients to create aggregated

(summary) patient data which GTH may share with third parties, including researchers, partners,

foundations, policy makers and other funding sources to help us apply for funding, prepare reports,

advocate on behalf of patients, or perform other health related research.

10. I attest that I am not receiving financial assistance for the expenses for which I am seeking assistance

from GTH. If applicable, in the event I become qualified for Medicaid coverage and in connection

therewith, or otherwise, become entitled to a refund of insurance premiums, I agree that GTH shall be

entitled to receive such refunds and I will transfer any such refunds I receive to GTH immediately.

11. If applicable, I understand that I must submit my health insurance reimbursement as soon as possible after

payment and GTH will not pay claims received more than 120 days after payment date.

12. I understand that GTH is not an emergency fund and no payments are made automatically.

13. I understand that in no event shall GTH be liable in any way for damages alleged to result from errors or

delays in the processing of Program applications or the issuance of payments as part of the Program, my

choice of health care provider or the success or failure of any therapy or treatment I obtain using funds

from the Program.

By signing below, I attest that I have read, fully understand and agree to the Applicant

attestation set forth above.

Applicant's Name (Please Print)

Applicant's Signature Date

5

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (“PHI”)

Patient’s Name: __ Patient’s Date of Birth: __

I hereby request that my health care provider identified below disclose the PHI described below to Gateway to Hope

in connection with my application for assistance from Gateway to Hope.

Name of Health Care Provider: _______________________________________________________________

PHI To Be Disclosed: breast cancer related health information ___________________________________________________________________________________________

Acknowledgment: If my medical record contains information about drug/alcohol abuse, mental health treatment,

sexually transmitted diseases, HIV/AIDS testing/treatment or any other sensitive information, I agree to its

release. Check if you do not agree to release of sensitive information described herein: Do Not Agree

Date(s) of Service of PHI To Be Disclosed: All dates of services, unless otherwise specified below:

___________________________________________________________________________________________

Revocation Right: I understand that I have the right to revoke this Authorization at any time by submitting a notice

in writing to the above named healthcare provider at the address stated above and that the revocation will be

effective except to the extent that action has already been taken in reliance on this Authorization.

Expiration: This Authorization will expire 3 years from the date of my signature below, unless otherwise specified

herein:____________________________________

Re-Disclosure: I understand that the information disclosed by this Authorization may be subject to re-disclosure by

the recipient and no longer protected by Federal or state privacy requirements.

Signature: I understand that my treatment, payment, enrollment or eligibility for benefits may not be

conditioned on signing the Authorization. By signing this document, I hereby authorize the above

named provider to disclose my protected health information as specified in this document.

Signature of Patient or Personal Representative Date

If this Authorization is signed by the patient’s personal representative, indicate such representative’s authority

to act on behalf of the patient: _________________________________________________________________

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines® is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use, or application, and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2013.

Instructions: First please circle the number (0-10) that bestdescribes how much distress you have been experiencing inthe past week including today.

YES NO YES NOPractical Problems

Family Problems

Emotional Problems

Spiritual/religiousconcerns

Physical ProblemsChild careHousingInsurance/financialTransportationWork/schoolTreatment decisions

Dealing with childrenDealing with partnerAbility to have childrenFamily health issues

DepressionFearsNervousnessSadnessWorryLoss of interest inusual activities

AppearanceBathing/dressingBreathingChanges in urinationConstipationDiarrheaEatingFatigueFeeling SwollenFeversGetting aroundIndigestionMemory/concentrationMouth soresNauseaNose dry/congestedPain

s/feet

SexualSkin dry/itchySleepSubstance abuseTingling in hand

Second, please indicate if any of the following has been aproblem for you in the past week including today. Be sure tocheck YES or NO for each.

Other Problems: _________________________________________

________________________________________________________

SCREENING TOOLS FOR MEASURING DISTRESS

Extreme distress

No distress

10

9

8

7

6

5

4

3

2

1

0

10

9

8

7

6

5

4

3

2

1

0

NCCN Distress Thermometer for Patients

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines® is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use, or application, and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2013.

Instructions: First please circle the number (0-10) that bestdescribes how much distress you have been experiencing inthe past week including today.

YES NO YES NOPractical Problems

Family Problems

Emotional Problems

Spiritual/religiousconcerns

Physical ProblemsChild careHousingInsurance/financialTransportationWork/schoolTreatment decisions

Dealing with childrenDealing with partnerAbility to have childrenFamily health issues

DepressionFearsNervousnessSadnessWorryLoss of interest inusual activities

AppearanceBathing/dressingBreathingChanges in urinationConstipationDiarrheaEatingFatigueFeeling SwollenFeversGetting aroundIndigestionMemory/concentrationMouth soresNauseaNose dry/congestedPain

s/feet

SexualSkin dry/itchySleepSubstance abuseTingling in hand

Second, please indicate if any of the following has been aproblem for you in the past week including today. Be sure tocheck YES or NO for each.

Other Problems: _________________________________________

________________________________________________________

SCREENING TOOLS FOR MEASURING DISTRESS

Extreme distress

No distress

10

9

8

7

6

5

4

3

2

1

0

10

9

8

7

6

5

4

3

2

1

0

NCCN Distress Thermometer for Patients

COST – FACIT (Version 2)

English (Universal) 26 September 2017

Copyright 2014, FACIT and The University of Chicago Page 1 of 1

Below is a list of statements that other people with your illness have said are important. Please circle

or mark one number per line to indicate your response as it applies to the past 7 days.

Not

at all

A little

bit

Some-

what

Quite

a bit

Very

much

FT1 I know that I have enough money in savings, retirement,

or assets to cover the costs of my treatment .........................

0

1

2

3

4

FT2 My out-of-pocket medical expenses are more than I

thought they would be ..........................................................

0

1

2

3

4

FT3 I worry about the financial problems I will have in the

future as a result of my illness or treatment .........................

0

1

2

3

4

FT4 I feel I have no choice about the amount of money I

spend on care ........................................................................

0

1

2

3

4

FT5 I am frustrated that I cannot work or contribute as much

as I usually do .......................................................................

0

1

2

3

4

FT6 I am satisfied with my current financial situation ................ 0 1 2 3 4

FT7 I am able to meet my monthly expenses .............................. 0 1 2 3 4

FT8 I feel financially stressed ...................................................... 0 1 2 3 4

FT9 I am concerned about keeping my job and income,

including work at home ........................................................

0

1

2

3

4

FT10 My cancer or treatment has reduced my satisfaction with

my present financial situation ..............................................

0

1

2

3

4

FT11 I feel in control of my financial situation ............................. 0 1 2 3 4

FT12 My illness has been a financial hardship to my family

and me ..................................................................................

0

1

2

3

4