Patient Support Program

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, for up to an additional $500 per patient per year). Assistance is provided on a first come first serve basis and is subject to funding availability.
Your Name*

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

First NameLast Name
Applicant Gender*
Applicant Age Range*
Applicant Ethnicity*
Applicant Zip Code*
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
How much assistance are you requesting?*
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.
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
You chose reimbursement; be sure to provide a receipt of payment and how reimbursement will benefit the patient over direct payment of outstanding bills below in the supporting documentation upload.
How would you prefer we make the payment:*

Check Payment by MailCredit Card Payment
Check Payment via Mail

Please fill out the information below if we are paying via check by mail.
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:
Credit Card Payment

Please fill out the information below if we need to pay by credit card over the phone or online.
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.
Cancelof
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:

Patient Support Program

Check Payment via Mail

Credit Card Payment