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  • Harrington Cancer & Health Foundation

    (806) 242-2425 | www.hchfamarillo.org

  • Solicitud de subvención para pacientes con cáncer que necesitan apoyo

  • Objetivo: Ayudar económicamente a los pacientes con cáncer que están económicamente estresados y se están sometiendo a tratamientos oncológicos.

    Elegibilidad: Para ser elegible para recibir asistencia financiera, debe tener un diagnóstico de cáncer confirmado por un proveedor de atención médica de oncología local y estar en tratamiento activo (quimioterapia/radiacion) que haya sido diagnosticado en los últimos 24 meses. Es posible que esto no incluya algunos tratamientos a largo plazo que pueden tomarse durante varios años después del tratamiento activo para mantener la remisión. El personal de HCHF revisará la elegibilidad para su aprobación.

    Los pacientes con cáncer pueden solicitar asistencia en las siguientes áreas:

    • servicios públicos (gas, electricidad, agua)  
    • Hipoteca/ Renta
    • Primas de seguro COBRA
    • Asistencia de gas (si viaja)
    • Asistencia de alojamiento (si viaja)
    • Co-país de prescripciónes de Texas Oncology

    NECESARIO para el procesamiento de solicitudes

    • Incluya documentación de apoyo con la solicitud: documentos de verificación de ingresos (1 paystub)
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  • Formulario completado por: (Rellene si no es solicitante) 

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  • 4. Describe brevemente la situación del solicitanten - 

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  • Gastos mensuales

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  • Gastos médicos no cubiertos por terceros o seguros:

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  • Por favor envíe una solicitud COMPLETA con la documentación requerida (envíe la documentación requerida a continuación)

    • Email: mariibelrivera@hchfamarillo.org
    • Fax: (806) 331-2401
    • Preguntas: (806) 331-2400 (Seleccione la opción 2 en el menú del correo de voz))

    *Todos los pagos se realizan directamente a empresas y no a particulares. La asistencia para el gas se da en forma de tarjetas de gas.

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    Recursos GRATUITOS para pacientes con cáncer desde el momento del diagnóstico.

    Para explorar todos los recursos ofrecidos a través de Harrington Cancer & Health Foundation y el Cancer Survivorship Center, visite hchfamarillo.org

     

    Cancer Survivorship Center

    1732 Hagy Blvd

    Amarillo, TX 79106

    (806) 242-2425

  • Autorización para Revelar Información Confidencial

    Instructions on next page

     

  • Yo autorizo que el proveedor de servicios de salud, consejero, etc.:

  • al siguiente individuo:

  • Esta información revelada puede ser usada por el individuo, o la organización representada por el individuo para las siguientes propósitos:

    ESTA AUTORIZACIÓN ES EFECTIVA HASTA QUE YO LO RENUNCIE EN MANO ESCRITA

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  • NOTIFICACIÓN SOBRE PRIVACIDAD

    Tan solo por unas cuantas excepciones, usted tiene el derecho de solicitar y de ser informado sobre la información que el Estado de Texas reúne sobre usted. A usted se le debe conceder el derecho de recibir y revisar la información al requerirla. Usted también tiene el derecho de pedir que la agencia estatal corrija cualquier información que se ha determinado sea incorrecta. Diríjase a http://www.dshs.state.tx para más información sobre la Notificación sobre privacidad. (Referencia: Government Code, sección 552.021, 552.023, 559.003 y 559.004)

  • Instructions for Obtaining Consent to Release Confidential Information

     Release form on previous page

  • Information contained in client records is confidential. With certain exceptions, the release of medical records is prohibited by the provisions of the Medical Practice Act (Article 4495b, V.T.C.S.). In addition, social, financial, educational and other types of information in client files may be protected by a constitutional or common law right to privacy. There are civil and criminal penalties for the unauthorized release of such information.

    The Medical Practice Act, the common law and the Constitution permit a health care provider to release these types of information from an individual's record with the consent of the individual or a person authorized to consent for the individual. For example, the Medical Practice Act states:

    Occupations Code Sec. 159.005(a)(1-5) and (b). Consent for the release of confidential information must be in writing and signed by the patient, or a parent or legal guardian if the patient is a minor, or a legal guardian if the patient has been adjudicated incompetent to manage his personal affairs or an attorney ad litem appointed for the patient, as authorized by the Texas Mental Health Code; the Persons With Mental Retardation Act; Chapter XIII, Texas Probate Code, and Subtitle B Title 5, Family Code; or a personal representative if the patient is deceased, provided that the written consent specifies the following:

    (A) the information or medical records to be covered by the release;

    (B) the reasons or purposes for the release; and

    (C) the person to whom the information is to be released.

    Further, the Communicable Disease Prevention and Control Act (Chapter 81, Health and Safety Code) contains the following specific requirements for the release of information relating to tests for AIDS, the human immunodeficiency virus (HIV), and antibodies to HIV:

    Sec. 81.103(d). An Authorization under this subsection must be in writing and signed by the person tested or the person legally authorized to consent to the test on the person's behalf. The authorization must state the person or class of persons to whom the test results may be released or disclosed.

    The "Authorization to Release Confidential Information" form was developed to conform to these statutory requirements. For this reason, when you are requested to release information from records under your control, the form must be carefully completed to provide the information required by statute. If you are requested to provide information from a client record to an institution (e.g., a hospital) rather than an individual, and you do not know the name of the individual within the institution to whom the information is to be sent, insert the title of the responsible person (e.g., the administrator, medical records librarian, etc.). Do not simply insert the name of the hospital.

    The "Authorization to Release Confidential Information" form must be completed and signed by individual clients when they request their personal health records be released.

    The form may be used to obtain information from other providers and when used for that purpose, it should be completed with the same concern for the statutory, common law and constitutional requirements. Such attention to detail may ultimately save both time and effort.

    The Medical Practices Act, the Communicable Disease Prevention and Control Act and certain other statutes, for instance, those relating for mental health and mental retardation information, provide several other exceptions to the rule of confidentiality relating to medical records.

    ANY REQUEST FOR INFORMATION WHICH CANNOT BE ADDRESSED BY THE USE OF THE CONSENT TO RELEASE CONFIDENTIAL INFORMATION FORM MUST BE REFERRED IMMEDIATELY TO THE OFFICE OF GENERAL COUNSEL FOR NECESSARY ACTION. Because the Public Information Act and other statutes give a very limited time period during which the agency must respond to requests for information, any delay in making these referrals may lead to results which are adverse to the agency.

    Please review the release form before releasing information. All blanks on the form must be filled in, the form must be read by the client, and the form must be appropriately signed before the information is released. The client must receive a signed copy of the authorization.

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