Medical/Travel Assistance
Request Form
Applicant Information
Salesforce Program Name
Patient Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Primary Phone Number
*
Please enter a valid phone number.
Patient Date of Birth
*
-
Month
-
Day
Year
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May CDF provide you with updates and mailings?
Yes, subscribe me to this newsletter.
Do you confirm, under penalty of perjury, that the person stated above has been diagnosed with cystic fibrosis?
*
Yes, I confirm.
I give permission to CDF to use my photographs, application, question responses, thank you notes, etc to help demonstrate the impact of this program to the public through the CDF website and social media channels.
*
Yes
No
Complete this section if the applicant is a minor or guardian is filling for an adult child.
Otherwise, continue to the next page.
Open this section if the applicant is a minor
Guardian
First Name
Last Name
Relationship to Applicant
Email
example@example.com
Phone Number
Please enter a valid phone number.
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Media Release
I give permission to the Cody Dieruf Foundation [CDF] to publicize my, or my child's, photographs, application responses, and other forms of communications for marketing and outreach purposes. I understand these purposes may include physical publications in print advertising, appeal letters, flyers, and/or brochures as well as digitally on our website and social media accounts. I further understand that this release is optional, and that I may refuse by not signing below.
Applicant or Guardian's Signature
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Medical Expense Information
Please select the type of medical expense you are requesting assistance for from the list below. You may select multiple types in one application. The Cody Dieruf Foundation prefers to pay for medical expenses ahead of time, but will reimburse expenses as well.
Open this section to apply for assistance with travel costs
CDF can cover the costs of travel for medically related appointments. We prefer to book hotels if possible because CDF will get a discount in Billings. If financial assistance is required prior to travel we require permission to speak with your CF social worker. CDF can provide financial assistance prior to travel or reimburse for travel after it has ocurred. CDF will need receipts for expenses after travel has occurred.
If funds are required before travel, can CDF speak with your CF social worker regarding this trip?
*
Yes
No
N/A not requesting funds prior to travel
Name of travel destination
Date of travel
*
What city and state is that located in?
Has this travel already occurred?
*
Yes
No
Did/does this travel require an overnight stay?
*
Yes
No
If yes, what is/was the length of the stay?
*
Briefly describe the medical reason for this travel
*
Cost Breakdown
Cost
Airline Travel
Cost of fuel for automobiles
Other modes of travel
Hotel
Food
Childcare expenses incurred by travel
Miscellaneous associated expenses
Total Cost of Travel
This is calculated automatically from you cost breakdown.
Open this section to apply for assistance with out-of-pocket expenses
What is the reason you've accrued an out-of-pocket medical cost(s)?
Are these costs related to medical care, health maintenance, etc., which provide some health benefit to the patient?
Yes
No
Has the patient's provider prescribed, recommended, and/or suggested the expenditure listed above?
Yes
No
Provider's Name
*
Clinic's Name
*
Provider's Phone Number
Please enter a valid phone number.
Briefly describe your expenses, as well as the cost per expense
Enter the total expense
*
Have you already paid for these expenses?
Yes
No
If yes above, how much of the total expense have you already paid?
Upload insurance documentation
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Please submit insurance documentation showing your annual deductible and proof that you have had to pay and/or must pay this entire amount in the current calendar year.
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Open this section to apply for a special life experience
Describe the cystic fibrosis patient's desired special life experience
Enter the estimated cost(s) of the special life experience
Submit a personal statement
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If the cystic fibrosis patient is old enough and/or able to write or express themselves, please attach a statement of one to three pages prepared by the patient why this experience is important to them and how the experience will make their life better. If the patient is too young or unable to write or express their special life experience, the applicant is asked to submit a personal statement on behalf of the patient. A short video of at least thirty seconds may also be submitted in lieu of a written statement. Please upload said files here.
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Submit Receipts
If there are any expenses you have already paid and are seeking reimbursement for, please submit receipts for those using the form below.
Upload Receipts or email receipts to pam at pam@breathinisbelievin.org
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This can be a photograph of the form or a formal scanned document.
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Please verify that you are human
*
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