Special Financial Assistance Application Form

We appreciate that the nature of CF can provide some challenges to your finances with unexpected expenses and that this can be stressful. To assist our members, we can provide one-off special financial assistance to get you through these occasions and hopefully make it less stressful for you.

Eligibility:

Membership of CFT must be current;
Available to all adults and children with CF;
Demonstrated hardship due to individual circumstances.

Entitlement:

Up to $1000 per annum, paid in one or multiple instalments, which can be used towards items such as unexpected medical costs, utility bills or other items. All applications are assessed on a case-by-case basis and submitting an application does not mean a claim will be automatically approved.
Circumstances need to be verified by the CF Social Worker or another Allied Health or Medical Professional;
Proof of costs needs to be provided eg a quote or invoice for medical-related costs, a copy of the utility bill etc.
If you are a Concession Card Holder you will be required to upload a copy of it with this application.

Process:

1. Prior to completing this form, please discuss your needs with the CF Social Worker or other Allied Health or Medical Professional. This is an important part of verifying your request.

2. Complete this form and attach any necessary supporting documentation.

3. The form can be filled out by someone else on your behalf, i.e. a loved one, CF Clinic staff member or anyone else you nominate.

4. Lodge the form with CFT for your claim to be processed. We endeavour to complete this within 10-14 days (depending on staff availability).

Name of Member requesting assistance. *

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Post Code

Email address of member*

Confirmation Emailexample@example.com

Mobile Number*

Phone Number

Details of person completing this form (if different from above)

Name

Street Address Line 2

Relationship

Mobile Number

Email address of person completing the form

Confirmation Emailexample@example.com

Does the member seeking assistance have a concession card?*

YesNoI don't know

If you answered "yes" to above, what type of concession card and when does it expire?

Please include the type of card eg Health Care Card, Disability Pension etc and include its expiry date.

Have your, or the member requesting the assistance, discussed your application with the CF Social Worker or an Allied Health or Medical Professional?*

YesNoI don't know

If you answered "yes" to above, who did you speak to?

Please list their name and their location eg John Smith, RHH.

Please tell us what you would like help with. Please list each item, amount and whether the bill has been already paid. If you indicate that the bill has not yet been paid then we will pay it directly to the supplier/provider. For example. "Car registration - $368 - Not yet paid". If this information is not supplied properly there may be a delay in payment. At the next question you will also be asked to upload the documents as proof and to enable CFT to make the payment to your or directly to the supplier. *

Please upload any supporting documentation such as invoices, quotations, copy of concession cards etc here.

Browse Files

BANK ACCOUNT DETAILS FOR PAYMENT OF FUNDS

Bank account holder*

Name

BSB*

Account Number*

Relationship to member with CF*

Eg self , parent, spouse etc.

DECLARATION

I declare that all information I have provided to Cystic Fibrosis Tasmania is true and accurate. I understand if it is found that I have knowingly provided false or inaccurate information I may no longer be eligible to be a member, or receive any or all of the services and benefits provided by Cystic Fibrosis Tasmania.

I also authorise Cystic Fibrosis Tasmania to contact any health professionals to verify the information provided in this application.

E-Signature Name*

Date*

Date

SPECIAL FINANCIAL ASSISTANCE APPLICATION FORM

We appreciate that the nature of CF can provide some challenges to your finances with unexpected expenses and that this can be stressful. To assist our members, we can provide one-off special financial assistance to get you through these occasions and hopefully make it less stressful for you.

Eligibility: