*New* FISHING FOR THE FIGHT APPLICATION FOR ASSISTANCE

FISHING FOR THE FIGHT APPLICATION FOR ASSISTANCE

This application has four parts. 1: Applicant Information 2: Physician Statement 3: Expense Form 4: HIPAA Release
Date of Application*

MonthDayYear
Date
Name of Applicant (Patient)*
Applicant's Birthday*
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Country CodeArea CodePhone Number
Driver’s License or State ID Number (If the application is for a minor without a driver's license, please input parent or guardian's information)*
Are you a resident of Sublette County or LaBarge, Wyoming?*

YesNo
If yes, how many years have you been a resident of Sublette County or LaBarge, Wyoming?
If yes, how many months of each year do you reside in Sublette County or LaBarge, Wyoming on a full time basis?
Please describe the medical condition for which you are seeking assistance.*
Name of person filling out this form*
Are you applying as a parent, guardian, or self?*

ParentGuardianPatient (self)
If you are applying as a parent or guardian, please list your name below.
If applying as a parent or guardian, you certify you have the legal authority to do so.*

YesNoI am not applying as a parent or guardian
By signing below, I am certifying that I meet the eligibility requirements for assistance and the information provided above is true and accurate to the best of my knowledge. Further, I have read and understand this Application, Fishing for the Fight’s HIPAA policy and Fishing for the Fight’s Travel and Expense Policy, and agree to the terms, conditions, and limitations contained therein. I also expressly represent that I am not receiving and have not received reimbursement for any expense submitted to Fishing for the Fight from any other source, including, but not limited to, insurance or other charitable or religious organizations. I further acknowledge that any receipt of reimbursement or payment for travel or Other Expenses from Kickin’ Cancer is expressly conditioned on my acceptance of Fishing for the Fight’s Travel and Expense Policy. I also acknowledge that review of this application for assistance, and the determinations made related to same, are within the sole and exclusive discretion of the Board.
Signature*
Part Two

Physician Statement
I understand that a signed statement from my treating physician is required before my application is complete. Physician statements can be uploaded below, emailed to BoardFFF@gmail.com, or mailed to Fishing for the Fight, PO BOX 1038, Pinedale WY 82941*

I have read the above and understand that I need a physician statement in order for my application to be considered.
I am a repeat applicant and have provided a physician's statement in the last 12 months. (If yes, no new statement is required at this time.)*

YesNoN/A
I am a repeat applicant and it has been longer than 12 months since I have provided a physician's statement. I will have a new statement sent in to Fishing for the Fight.*

YesN/A
Please upload physician's statement below.

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Part Three: Expenses
Please describe your current needs, specifically detailing any out-of-pocket expenses that are not reimbursed or covered by insurance. Examples include travel expenses related to receiving treatment and costs of treatment not covered by your insurance, if recommended by your treating physician. *Please note: receipts and insurance EOB statements can be uploaded below.*
Are you a beneficiary, or policyholder, on any insurance policy that may provide coverage for out of pocket or supplemental expenses? If so, please provide the policy number and details of coverage.*
Reason for disclosure (Choose one)*

Treatment/Continuing Medical CareBilling or ClaimsLegal PurposesSchool/EmplooymentDisability DeterminationOther
Name of Treating Physician*
Phone Number of Treating Physician*
Please enter a valid phone number.Format: (000) 000-0000.
Address of Treating Physician*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Treatment appointments for which you are seeking assistance.

We cannot assist with appointments that may take place in the future; all appointments must already have taken place. Receipts, physician invoices, insurance EOB's, and/or other documentation should be kept and must be provided upon request.
Date of appointment, treatment, or hospitalization*

MonthDayYear
Date
List the city and state of appointment, treatment, or hospitalization*
Please provide a description of what you were seen for.*
How many people traveled to this appointment?*
Did this appointment require you to stay overnight?*

YesNo
If this appointment required an overnight stay, please list the number of nights.
I understand that I must email my lodging receipts to BoardFFF@gmail.com in order for my reimbursement to be considered.*

YesI am not requesting reimbursement for overnight stays.
Please upload hotel receipts that correspond to dates requested, if applicable.

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Please upload insurance EOB statements that correspond to requests, if applicable.

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If you have additional appointments you'd like to enter, please input them below. If not, proceed to section four.
Date of appointment, treatment, or hospitalization

MonthDayYear
Date
List the city and state of appointment, treatment, or hospitalization
Please provide a description of what you were seen for.
How many people traveled to this appointment?
Did this appointment require you to stay overnight?

YesNo
If this appointment required an overnight stay, please list the number of nights.
I understand that I must email my lodging receipts to BoardFFF@gmail.com in order for my reimbursement to be considered.

YesI am not requesting reimbursement for overnight stays.
Date of appointment, treatment, or hospitalization

MonthDayYear
Date
List the city and state of appointment, treatment, or hospitalization
Please provide a description of what you were seen for.
How many people traveled to this appointment?
Did this appointment require you to stay overnight?

YesNo
If this appointment required an overnight stay, please list the number of nights.
I understand that I must email my lodging receipts to BoardFFF@gmail.com in order for my reimbursement to be considered.

YesI am not requesting reimbursement for overnight stays.
By signing below, I am certifying that I meet the eligibility requirements for assistance and the information provided above is true and accurate to the best of my knowledge. Further, I have read and understand Fishing for the Fight’s Travel and Expense Policy, and agree to the terms, conditions and limitations contained therein. I also expressly represent that I am not receiving and have not received reimbursement for any expense submitted to Kickin’ Cancer or from any other source, including, but not limited to, insurance or other charitable or religious organizations.
Signature*
Part Four

HIPAA Release
Authorization to Release Health Care Records

Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information.

IMPORTANT INFORMATION ABOUT THE AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

This form is intended for use in complying with the requirements of the Health Insurance Portability and Accountability Act and Privacy Standards (HIPAA) and Wyoming medical privacy laws.

Health Information to be Released - If "All Health Information" is selected for release, health information includes, but is not limited to, all records and other information regarding health history, treatment, hospitalization, tests, and outpatient care, and also educational records that may contain

As indicated on the form, specific authorization is required for the release of information about certain sensitive conditions, including: Mental health records (excluding "psychotherapy notes" as defined in HIPAA at 45 CFR 164.501Drug, alcohol, or substance abuse records. Records or tests relating to HIV/AIDS. Genetic (inherited) diseases or tests (except as may be prohibited by 45 C.F.R. § 164.502

Note on Release of Health Records - This form is not required for the permissible disclosure of an individual's protected health information to the individual or the individual's legally authorized representative. (45 C.F.R. §§ 164.502(a1i

If a healthcare provider is specified in the "Who Can Receive and Use The Health Information" section of this form, then permission to receive protected health information also includes physicians, other health care providers (such as nurses and medical staff) who are involved in the individual's medical care at that entity's facility or that person's office, and health care providers who are covering or on call for the specified person or organization, and staff members or agents (such as business associates or qualified services organizations) who carry out activities and purposes permitted by law for that specified covered entity or person. If a covered entity other than a healthcare provider is specified, then permission to receive protected health information also includes that organization's staff or agents and subcontractors who carry out activities and purposes permitted by this form for that organization.

Right to Receive Copy - The individual and/or the individual's legally authorized representative has a right to receive a copy of this authorization.
I certify that I have read the above statement*

Yes
I AUTHORIZE THE RELEASE OF MY PROTECTED HEALTH INFORMATION TO FISHING FOR THE FIGHT FOR THE PURPOSE OF DETERMINING FINANCIAL ASSISTANCE.

I UNDERSTAND THAT FISHING FOR THE FIGHT WILL KEEP MY INFORMATION CONFIDENTIAL AND WITHIN THE FISHING FOR THE FIGHT ORGANIZATION, UNLESS OTHERWISE AGREED UPON BY BOTH PARTIES.

I AUTHORIZE FISHING FOR THE FIGHT TO DISCLOSE THE INDIVIDUAL PATIENT REFERENCED ABOVE'S PROTECTED HEALTH INFORMATION TO MEMBERS OF THE FISHING FOR THE FIGHT ORGANIZATION.

I CERTIFY THAT I HAVE THE LEGAL AUTHORITY TO SIGN ON BEHALF OF MYSELF OR THAT I HAVE THE LEGAL AUTHORITY TO SIGN ON BEHALF OF THE APPLICANT AS A LEGAL PARENT OR GUARDIAN.
I certify that I have read the above statement*

Yes
WHAT INFORMATION CAN BE DISCLOSED? The signature of a minor patient is required for the release of some of these items. If all health information is to be released, then check only the first box.*

All Health InformationPhysician's OrdersProgress NotesPathology ReportsHistory/Physical ExamOther
Your initials are REQUIRED to release the following information. Place initials in boxes below as applicable.
Mental Health Records (excluding psychotherapy notes)
Drug, Alcohol, or Substance Abuse Records
Genetic Information (including Genetic Test Results)
HIV/AIDS Test/Results/Treatment
EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reaching the age of majority; or permission is withdrawn; or 48 months from the date of execution for existing health information and 12 months for health information created after the effective date of this authorization.

RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under "WHO CAN RECEIVE AND USE THE HEALTH INFORMATION."

I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures required or permitted under Wyoming Law and/or 45 C.F.R. § 164.502(a1

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.
I certify that I have read the above statement.*

Yes
Right to name a person that may receive my PHI from Fishing for the Fight

I (patient, parent, or guardian) authorize the following individual to contact, work with, and supply my PHI to FISHING FOR THE FIGHT on my behalf, and to receive information from FISHING FOR THE FIGHT related to my PHI.
Name of Person Authorized to Receive and Supply Information:

First NameLast Name
Relationship of Person to Individual (Patient)

SpouseParent/Legal GuardianMedical Power of AttorneyOther
By signing below, I certify that I have reviewed, read, and agreed to Fishing for the Fight's HIPAA policy. Signature of Individual or Individual’s Legally Authorized Representative if the individual is a minor or otherwise incapacitated.*
A minor individual's signature may be required for the release of certain types of information, including for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment:
Minor's Signature, as applicable
Please provide any other information you'd like to include on your application.
If you have any questions about this application, email boardfff@gmail.com. All information in this application is kept confidential.
Should be Empty:

FISHING FOR THE FIGHT APPLICATION FOR ASSISTANCE

Part Two

Part Three: Expenses

Treatment appointments for which you are seeking assistance.

Part Four