AIOF Patient Support Fund

AIOF Patient Support Fund
When all other means are unavailable, the AIOF Patient Support Fund serves as a safety net to provide financial support to meet Alaskans' unique individual needs and address barriers to care as they undergo cancer treatment. Assistance is offered for expenses such as transportation, lodging, basic necessities, medications, and other items necessary for care.

Support is offered to eligible patients regardless of where care is received. This could be surgical oncology, medical oncology, or radiation oncology providers. The financial support provided includes up to $1,000 per patient per year. Assistance is provided on a first-come, first-served basis and is subject to funding availability.

Eligibility Requirements – By certifying below you attest that the applicant meets the following criteria:

1. Patient has a diagnosis of cancer and are receiving treatment under the care of a physician.

2. Financial support is necessary to gain access to care.

3. Necessary support is not covered by insurance or other available resources (grants, community providers, etc.)
I certify that the applicant meets the eligibility requirements as outlined above*

Yes
Your Name*

First NameLast Name
Your Organization*
Your Phone Number*
Please enter a valid phone number.
Your Email*
example@example.com
Applicant Information
Name of Applicant*

First NameLast Name
Applicant Phone Number*
Please enter a valid phone number.
Applicant Date of Birth*

MonthDayYear
Date
Applicant Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant Gender*
Applicant Age Range*
Applicant Ethnicity*
Applicant Employment Status*
Other Employment Status
Applicant Household Size*

1234+
Applicant Household Monthly Net Income*
$
What other funds did this patient contact for assistance prior to this request? (select all that apply)*

ACS Transportation GrantACS Lodging GrantACS Road to RecoveryAspen Cancer Care Hotel ProgramCancer Specific Funds (Pink Fund, Susan G. Komen, etc.)Angel FlightsDental Lifeline NetworkOther
Applicant Zip Code
What other funds has this patient contacted for assistance?
Eligibility Requirements - all criteria are required for application to be processed

Applicant has a diagnosis of cancer and is under the care of a physician (generally defined as consent for treatment).Applicant needs financial support to gain access to care.Necessary support is not covered by insurance or other available resources (grants, community providers, etc.)Applicant has a documented financial need for support
What type of assistance are you applying for? Choose all that apply:

TransportationLodgingBasic NecessitiesMedical Expenses (Note: we are unable to pay medical bills at this time, but can pay for other medical expenses such as prescriptions, wheelchairs, etc.)Other
What type of assistance is requested?*

Rental AssistanceLodging/HotelUtilitiesFlightsMedicationsDMEOther
Total Amount Requested*
Note: Please put exact amount requestedthat matches supporting documents. Multiple requests can be made in one year to meet allotted amount of $1,000 per year per patient.
Is this a time sensitive need?*

YesNo
If this is a time sensitive need, please explain:
Are you requesting a total amount over $1,000?*

YesNo
Total amount being requested
$
Please identify how you will submit Explanation/Reason for Request*

Upload copy of patient's written statementType out reasoning below
Upload a copy of the patient's written statement:

Cancelof
Provide patient reasoning for need below:
Waiver Request

I am requesting that you waive the limit on funds allowed & have provided documentation below.
Document Upload
What Verification of Household Income documents are attached?*

Most recent tax return or W-2Last three paystubsProof of government assistance (Medicaid, SNAP, etc.)Social Security Verification LetterFinancial Assistance Approval LetterOther supporting document type
Verification of Household Income Documents*

Cancelof
Which Supporting Appendix document is attached?*

Appendix A – Rental AssistanceAppendix B – Utility/Bill AssistanceAppendix C – Flight AssistanceAppendix D – Other Assistance
Supporting Appendix Documents*

Cancelof
What type of document is provided to support/show specific amount being requested?*

Monthly Utility Statement/BillRental AgreementPhone BillHotel Reservation ConfirmationOther Supporting Document
Supporting Amount Requested Documents*

Cancelof
Waiver Need
Please document why the patient needs a waiver for additional funds.
Payment Type

ReimbursementDirect PaymentOther
Is this an emergent need? (i.e. the utilities are about to be turned off)

YesNo
How would you prefer we make the payment:

ACH (Preferred)Check Payment by MailCredit Card Payment
Bank Name
Bank Routing Number
Bank Account Number
Bank Account Type

CheckingSavings
Who do we make the check out to?
Address where check is to be sent:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Number and Patient Address for Check Memo:
Will we be making the credit card payment online or by phone?

OnlineBy Phone
Primary person to contact for payment

First NameLast Name
Number to call for payment
Please enter a valid phone number.
Account Number (if applicable)
Website to pay online
Where should the payment be sent?
Please include all applicable information such as name, address, any applicable account numbers so that we can process a payment.
Explanation of Need
Please summarize the needs of the applicant.
Demonstration of Need

Attached below is documentation of financial need through one of the following: recent tax returns or last three months pay stubs. Proof of government assistance (e.g., SNAP, Medicaid, SSDI), employment verification letters can also be included.
Supporting Documentation

Please include documentation that supports eligibility requirements. Any items requested for reimbursement please include receipt of payment. For items requesting payment, please include invoice showing amount and vendor information to submit payment.
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Terms & Conditions

I certify that the above facts are true to the best of my knowledge and belief
Please verify that you are human*
Should be Empty:

AIOF Patient Support Fund

Applicant Information

Document Upload