The Janice Workcuff C. A. R. E. Legacy Form

The Janice Workcuff C.A.R.E. Legacy Program FORM

SUPPORTING

Houston, Texas and surrrounding counties only.

Brazoria, Chambers, Fort Bend, Harris, Galveston, Liberty, Montgomery and waller

at the end of each quarter for that month

January, February March

April,May, June

July, August, September

October, November, December

I. C.A.R.E PROGRAM PURPOSE

The Janice Workcuff C.A.R.E. Legacy Program provides compassionate support to individuals coping with the care and aftermath of breast cancer. ASC’s primary focus is to assist patients and their families with critical financial needs that arise because of treatment, recovery, and survivorship.

Patients seeking assistance must demonstrate financial need through a completed application and required verification documentation.

While ASC strives to assist every individual who contacts our office, funding is limited and specific eligibility requirements must be met. Approved patients may receive financial assistance during a designated assistance period based on the organization’s fiscal year and available resources.

Services are provided based on demonstrated need and program availability. ASC is unable to reserve or hold funds for future use, and financial assistance cannot be guaranteed at the exact time of request due to funding availability.

II. ELIGIBILE EXPENSES UNDER C.A.R.E.

ASC’s C.A.R.E. Program supports the following needs:

Breast cancer medical co-payments
Prescriptions related to breast cancer medical care
Utility assistance to patients undergoing treatment
Gas cards for patients undergoing treatment to get to and from treatments
Metro cash cards for patients undergoing treatment, to get to and from treatments. Uber or Lyft LIMIT.
Groceries to support underage children of parent(s)/patient(s) undergoing treatment
Cell phone limit with receipt notice.

IV. INELIGIBLE EXPENSES
The ASC Janice Workcuff C.A.R.E. Legacy Program does not make payments for any medical treatments, insurance deductibles, car payments, car insurances, cable television, internet services. ASC only provide additional resource information.
V. SUPPORT DOCUMENTENTATION REQUIRED
Clients that receive services from the ASC Janice Workcuff C.A.R.E. Legacy Program are required to provide a copy of their Texas issued Identification Card or Driver’s License, Proof of Diagnosis of Breast cancer, utility bill with the same address as state issued identification.

The following documentation is needed to receive services:

Medical Co-payments require a statement from the patient’s insurance company or the Doctors office that details the due co-payment. ASC Janice Workcuff Legacy C.A.R.E. Program.
Prescription assistance is provided on a reimbursable basis. A patient is required to submit the receipt for cancer drugs only to the ASC Janice Workcuff Legacy C.A.R.E. Program for reimbursement. On a case by case bases a client may request an advance for Prescription assistance. Advance payment for prescription drugs can only be approved by the Executive Director of Angel’s Surviving Cancer.
Utility assistance can only be provided with a proof of delinquent payment and/or disconnection notice. The utility services must be for the residence in which the patient resides. (water , Lights , Gas)
All clients are eligible for grocery assistance, if requested. Grocery assistance. Clients will be issued gift cards and required to submit receipt of purchases within ten (10) days of distribution. Failure to submit receipts will result in ineligibility of future services.
All clients are eligible for Gas Cards/Metro Cash Card. Cards will be distributed on an as needed basis, if requested by patient.
Cell Phone (with Receipt)LIMIT
Offer resource training of life skills to be able to have productie living anf quality of life.

VI. HOW TO APPLY FOR SERVICES

All clients must apply to determine eligibility. Please note that it’s important to make sure that you fill out each part of this application. Applications that are not complete will not be processed. The Application process is brief and concise. In order to continue to serve cancer patients we ask that you please make sure everything is filled out, all copies requested are enclosed, and you send in a picture ID (legible copy).

VII. CONTACT INFORMATION
A client can apply via email or on our website at www.angelssurvivingcancer.org however all support documentation must be received prior to approval of services. Other information under Resource tab on our website.

Today's Date*

MM-DD-YYYY

YesNo

If no please explain how we can assist you to attend at least once*

Full Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNo

If other, Please tell us how we can assist.*

Stage of Breast Cancer:*

Please type unknown if stage of cancer is not known

Age at Diagnosis:*

YesNo

If yes, treatment dates:

Please list start date and finish date (even if it's a future date)

If yes, type/s of treatment:

YesNo

If no, please state reason:*

Please type N/A if not applicable

Please list all sources of income:*

Amount of request: $*

Please list estimated amount of funds or service requested

YesNo

Number of members in Houshold*

Under $25K$25K-$49,999K$50K-$69K$70K

Please explain the circumstances creating a financial need at this time:

YesNo

If yes, what size Bra do you wear?

If yes, do you have a physician prescription for bra or prosthesis?

YesNo

If yes to the following two questions, Please provide each child's age and size:

Please type N/A if not applicable

Referred by:*

YesNoN/A

Name of referring individual *

First NameLast Name

Email of referring individual

example@example.com

Phone Number of referring individual *

Please enter a valid phone number.Format: (000) 000-0000.

The Janice Workcuff C.A.R.E. Legacy Program PROFILE

ASC Offer life skill resource training to continue with productive living and quality of life after treatment in the workforce.