Patient Support Program
The AIOF “Patient Support Fund” has been created to address patient needs related to access to care and alleviate financial burdens for cancer patients. When other means are unavailable, the AIOF Patient Support Funds serves as a safety net to provide financial support to meet individual unique needs of Alaskans and address barriers to care as they are undergoing cancer treatment. Support is to be offered to qualifying patients regardless of where care is received. This could be surgical oncology, medical oncology, or competing radiation oncology providers. The financial support to be provided includes up to $1,000 per patient per year. (A waiver process is also available for extenuating circumstances where this amount is insufficient, up to $2500 per patient per year). Assistance is provided on a first come first serve basis and is subject to funding availability.
Your Name
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First Name
Last Name
Your Organization
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Your Phone Number
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Please enter a valid phone number.
Your Email
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example@example.com
Name of Applicant
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First Name
Last Name
Applicant Gender
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Please Select
Male
Female
Transgender
Non-binary/non-conforming
Applicant Age Range
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Please Select
Under 18
18–24
25–34
35–44
45–54
55–64
65-74
75-84
85-94
95 & Over
Applicant Ethnicity
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Please Select
White
Black
Alaskan Native
Asian
Hispanic and Latino
Pacific Islander
Other
Applicant Zip Code
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Eligibility Requirements - all criteria are required for application to be processed
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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:
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Transportation
Lodging
Basic Necessities
Medical 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
How much assistance are you requesting?
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Awards are limited to $1,000 per person per year. A waiver process is available if this amount is insufficient due to extenuating circumstances.
Waiver Request
I am requesting that you waive the limit on funds allowed & have provided documentation below.
Payment Type
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Reimbursement
Direct Payment
Other
Is this an emergent need? (i.e. the utilities are about to be turned off)
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Yes
No
Where should the payment be sent?
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Please include all applicable information such as name, address, any applicable account numbers so that we can process a payment.
Explanation of Need
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Please summarize the needs of the applicant.
Demonstration of Need
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Attached below is documentation of financial need through one of the following: recent tax returns, pay stubs, and bank statements to show income and account balances. Proof of government assistance (e.g., SNAP, Medicaid), employment verification letters, and unpaid expense statements (e.g., rent, utilities) can also be included.
Supporting Documentation
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Browse Files
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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
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I certify that the above facts are true to the best of my knowledge and belief
Please verify that you are human
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