Lucy's Children Application

Through the Lucy's Children program of Lucy's Love Bus, children in New England who have or had cancer receive between $500 and $1000 individual integrative therapies of choice each year, paid for by Lucy's Love Bus and provided by local, vetted and qualified practitioners. 

Eligibility requirements:

• Cancer diagnosis before the age of 21 years
• Living in New England OR currently being treated in New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont)

The following are NOT required: financial information; residency/citizenship information; a certain phase of treatment ie those in remission are still eligible for support. 

This is our online application form. For a downloadable copy, please click here.

We're so glad that you found us, and we can't wait to start working with your family and child!

Haga clic aquí para rellenar la solicitud en español.

Demographic information

We collect this important information so that we can operate efficiently, address disparities, and make a positive impact on the community we serve. All questions are optional and all information is confidential. Thank you for your help in providing this critical information!

HIPAA NOTICE OF PRIVACY POLICIES

This notice describes how your medical information may be used and disclosed and how your privacy is being protected at our non-profit organization.  The privacy of your medical information is important to us and we are committed to protecting your medical information.  We create a record of the care and services that are funded through our organization to provide you with quality care and to comply with certain legal requirements.  In order to maintain the level of service that you expect from our organization, we may need to share limited personal medical information.  This notice will also describe your rights and certain duties we have regarding the use and disclosure of medical information.

How Our Organization May Use or Disclose Your Health Information

Our organization collects health information about your child and stores it in a secure, HIPAA compliant online file. Your medical record is the property of our organization, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes: 

Treatment: We disclose your child’s medical information to our partnering integrative practitioners, employees and others who are involved in providing the care you need. For example, we may share your child’s medical information with other physicians, health care providers or other health care facilities that will provide services that we do not provide.  We may disclose medical information to family or others who can help you when you are sick or injured.

Health Care Operations & Payment: We use and disclose medical information about your child to obtain funding for the services we provide. For example, we may use and disclose this information to review and improve quality of care, or to report in the aggregate to our funders. (Your child’s name will NOT be used.)

Appointment Reminders: We may use and disclose medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.

Notification & Communication with Family: We may disclose your child’s health information to notify or assist in notifying a family member, your personal representative or another person responsible for your child’s care about your child’s location, your child’s general condition or in the event of your child’s death. We may also disclose information to someone who is involved with your child’s care or helps pay for your child’s care. If you are unable or unavailable to agree or object on behalf of your child, our health professionals will use their best judgment in communication with your family and others.

Required by Law: We will limit our use and disclosure of your child’s health information to relevant requirements of the law. When the law requires us to report abuse, neglect, domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.

Public Health: We may, and are sometimes required by law to disclose your child’s health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place your child at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.

Judicial and Administrative Proceedings: We may, and are sometimes required by law, to disclose your child’s health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about your child in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.

Law Enforcement: We may, and are sometimes required by law, to disclose your child’s health information to a law enforcement official for purposes such as identifying of locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes. 

Public Safety: We may, and are sometimes required by law, to disclose your child’s health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

When Our Organization May Not Use or Disclose Your Health Information

Our organization will not use or disclose health information that identifies your child without your written authorization except as described in this Notice of Privacy Polices. If you do authorize our organization to use or disclose your child’s health information for another purpose, you may revoke your authorization in writing at any time.

Your Health Information Rights
Right to Request Special Privacy Protections: You have the right to request restrictions on certain uses and disclosures of your child’s health information, by a written request specifying what information you want to limit and what limitations on our use or disclosure of that information you wish to have imposed. We reserve the right to accept or reject your request, and will notify you of our decision.

Right to Request Confidential Communications: You have the right to request that you receive your child’s health information in a specific way or at a specific location. For example, you may ask that we send information to a particular email account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.

Right to Inspect and Copy: You have the right to inspect and copy your child’s health information with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to and whether you want to inspect or copy the record. We will charge a reasonable fee, as allowed by Massachusetts law. We may deny your request under limited circumstances.

Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with this Notice. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received.

Questions and Complaints
Questions and complaints about this Notice of Privacy Practices or how our organization handles your health information should be directed to our Executive Director during regular business hours. If you are not satisfied with the manner in which our organization handles a complaint, you may submit a formal complaint without the risk of penalization to: Department of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Bldg., 200 Independence Avenue, S.W., Room 509F HHH Building, Washington, DC 20201.

PRIVACY POLICIES ACKNOWLEDGEMENT

I have received, read and understood the Notice of Privacy Policies of our organization.  I understand how Lucy’s Love Bus Charitable Trust may use or disclose my child’s health information.  I understand when Lucy’s Love Bus Charitable Trust may not use or disclose my health information. I understand my child’s health information rights and understand that Lucy’s Love Bus Charitable Trust reserves the right to change this Notice of Privacy Practices.  I also understand how to place a complaint regarding this Notice and have also been provided the opportunity to review and question the privacy policies of Lucy’s Love Bus Charitable Trust.

1. My Authorization

II.  My Rights

I may revoke this authorization in writing.  If I did, it would not affect any actions already taken by the above-named organization based upon this authorization.
To revoke this authorization:

• Write a letter to our Director at:
  Lucy’s Love Bus
  PO Box 464
  Amesbury, MA 01913

Once the office discloses health information, the person or organization that receives it may re-disclose it.  Privacy laws may no longer protect it.

LUCY’S LOVE BUS CHARITABLE TRUST, INC.
RELEASE AND WAIVER OF RIGHTS

             This Release and Waiver of Rights (hereinafter, this “Waiver”) is made on behalf of the participant {yourFull} (hereinafter, “Participant”).  Participant has requested the assistance of Lucy’s Love Bus Charitable Trust, Inc. and its respective volunteers, officers, directors, employees, agents, and affiliates (collectively, “Lucy’s Love Bus”) in identifying and collaborating with third party providers of certain services (hereinafter, “Provider(s)”).  Providers specialize in services including, but not limited to, acupuncture, massage, therapeutic horseback riding, Reiki, meditation, tai chi, art, music, dance, fertility preservation, therapies, medical support and other activities (collectively, “Services”), such that Providers can render their Services directly to Participant.

            Participant(s) hereby acknowledge and understand that Lucy’s Love Bus identifies, partners with, and makes referrals to Providers.  Participant(s), however, understand that Participant(s) are ultimately wholly responsible for and assume the entire risk of and determination as to whether a Provider and/or Provider Services are safe and proper for Participant.  Such determination includes, but is not limited to, whether a Provider is qualified and fit to adequately perform Services for Participant.  Participant(s) further acknowledge and understand that Participant(s) should consult with Participant’s medical professionals as to whether Provider Services could potentially harm Participant.  Participants(s) also acknowledge and understand that Provider Services and/or the location of Provider Services have the potential to pose certain risks which could lead to injuries and even death of Participant.

            In consideration of Lucy’s Love Bus’s identification of Providers and other services: 

1.     PARTICIPANT HEREBY ACKNOWLEDGES AND FULLY ASSUMES THE RISKS INHERENT IN PROVIDER SERVICES.  Such risks may include, but are not limited to, physical or psychological injury, property damage, or other physical, economic, or emotional losses, or other damages caused in part or in whole by the location of the activities, personal negligence, or the negligence of others, among other potential contributing factors.  After consideration of the risks inherent in Provider Services, including, but not limited to, those contemplated herein, Participant(s) hereby acknowledge and fully assume any and all risks in connection with referral by Lucy’s Love Bus and Participant’s participation in any and all Provider Services.

2.     PARTICIPANT HEREBY WAIVES ANY AND ALL CLAIMS AGAINST LUCY’S LOVE BUS ON THEIR OWN BEHALF. Participant agrees to waive and release and promise to indemnify, reimburse, defend, and hold harmless Lucy’s Love Bus against any and all legal or equitable claims and proceedings of any description, known or unknown, that Participant, and/or their respective heirs, have or may have in the future, directly or indirectly, against Lucy’s Love Bus for any losses, damages, expenses, or injuries, including, but not limited to, physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, property damage, and death, suffered from, or in connection with, referral by Lucy’s Love Bus and/or participation in any and all Provider Services.

3.     PARTICIPANT HEREBY AGREES, THAT, TO THE EXTENT ALLOWED BY APPLICABLE STATUTE OR CASE LAW, THIS WAIVER IS ALSO FOR NEGLIGENCE ON THE PART OF LUCY’S LOVE BUS.  Participant acknowledges and understands that the injuries and outcomes contemplated herein may arise from the negligence of others. Participant hereby agrees, that, to the extent allowed by applicable statute or case law, Lucy’s Love Bus shall not be liable to Participant for any negligence by Lucy’s Love Bus in connection with its referral of Providers or other services.

4.     PARTICIPANT HEREBY AGREES TO ARBITRATION, IN ACCORDANCE WITH MASSACHUSETTS LAW, IN THE EVENT OF ANY DISPUTE. In the event a dispute shall arise between Participant and Lucy’s Love Bus out of or relating to this Waiver or the construction, interpretation, performance, termination, enforceability or validity of this Waiver, Participant hereby agrees to binding arbitration in accordance with the then applicable American Arbitration Association Commercial Rules of Arbitration.  Further, Participant hereby agrees that such arbitration shall be the agreed upon exclusive dispute resolution for any and all matters arising between the parties to this Waiver, now or in the future.  In the event of arbitration, Participant and Lucy’s Love Bus shall mutually agree on a single arbitrator.  In the event that Participant and Lucy’s Love Bus cannot agree on a single arbitrator, each party shall appoint an arbitrator and those chosen arbitrators shall, in turn, mutually agree on a third arbitrator for a complete panel of three arbitrators.  The dispute(s) shall then be resolved by the single chosen arbitrator or the panel, in either case applying the substantive law of The Commonwealth of Massachusetts without regard to any applicable choice of law rules.  Any decision or award rendered by an arbitrator or panel shall be final and legally binding, and judgment may be entered thereon.

Each party shall be responsible for its share of costs associated with arbitration.  In the event a party fails to proceed with arbitration, unsuccessfully challenges the arbitrator’s award, or fails to comply with the arbitrator’s award, that party shall reimburse the other party for costs of the legal suit, including reasonable attorney’s fees, for having to compel arbitration or to defend or enforce the award.

5.     PARTICIPANT HEREBY AUTHORIZES AND CONSENTS TO PARTICIPATION IN PROVIDER SERVICES.  Participant acknowledges and understands that referral to and participation in Provider Services is completely voluntary, and that Participant is free to not participate in any Provider Services. After consideration of the risks inherent to participating in Provider Services, Participant hereby consents to, and authorizes, Participant’s participation in any and all such Services with full knowledge that Lucy’s Love Bus will not be liable to Participant for any related personal injuries or property damage that may occur.

Participant hereby acknowledges that they have read, understood, and agreed to this Waiver in its entirety, including, but not limited to, the above paragraphs numbered one through six (1 – 6).  Participant hereby agrees that signing below binds themselves and their respective heirs, successors, assigns, and estates to the terms and conditions described herein.  Participant further acknowledges that by signing below they have entered into this Waiver willingly and knowingly, without fraud, duress, or coercion by Lucy’s Love Bus.  Participant hereby agrees that this Waiver is an accurate understanding of the entire agreement between the parties on the subject, that neither party has relied on any outside representation or statement on the matters described herein, and that this Waiver has not been modified orally.  Participant hereby agrees that if any provision of this Waiver is or becomes illegal, unenforceable, or invalid in any jurisdiction for any reason, it shall not affect the enforceability or validity of any other provision of this Waiver.

Medical Permission Form

Please download this medical permission form and present to your child's oncologist for a signature indicating which therapies your child is medically cleared to participate in at this time.

If you already have this form signed, you can upload it here. 

Our Process

Once we receive the completed application for your child, we will confirm receipt and discuss current options for funding. Please allow up to two weeks for initial contact after you submit your application. We will reach out via your indicated preferred contact method to discuss funding availability.

• We must pay a provider directly; we cannot pay or reimburse families for services already received.
• Funding is awarded on an as-needed basis (not as an annual amount).
• Funding does not expire.
• We pride ourselves on matching your child with the best practitioner(s) to meet their needs. While we require proof of applicable certifications and licenses from the practitioners we work with, we require that you stay with your child throughout their appointment to ensure their safety and comfort.

By accepting funding from Love Bus, you agree to participate in one brief annual survey so that we can assess our programs and secure more funding for children with cancer. This survey is conducted by email or phone, consists of 5 questions, and takes less than 5 minutes to complete.

We appreciate your support in capturing the benefits of our work together. Thank you!

Lucy’s Love Bus has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your primary health care provider. By submitting your electronic signature, you acknowledge that all information submitted is true and accurate to the best of your knowledge.