Transplant Assistance Application Form

TRANSPLANT ASSISTANCE APPLICATION FORM
We appreciate that the costs of undergoing a transplant can be large, especially for the extended period of time you are likely to be interstate. Please complete this form to apply for CFT's Transplant Assistance.

Eligibility:
- Membership of CFT must be current;
- Available to all adults and children with CF;
- Available for all types of organ transplants.
Entitlement:
- Up to $1500 for each transplant
- CF's Hospital Inpatient Assistance cannot be claimed in addition to your admission for the transplant. However, pre and post-transplant hospital admissions can be claimed with that benefit using the relevant form for that.
Process:

1. Complete this online form when you start the process to be listed for a transplant.

2. The form can be filled out by someone else on your behalf, i.e. a loved one, CF Clinic staff member or anyone else you nominate.

3. You may want to consider if the money goes into your own personal account or that of a loved one. Immediately following the transplant, you may not feel like accessing your bank accounts. So choose the most appropriate option for you and/or your loved ones to access the money when required.

4. Lodge the form with CFT;

5. We will keep the form on file, and when we are advised by the CF Clinic that you have received your transplant, we will process the payment to your nominated bank account.
Name of person being assessed for transplant*

First NameLast Name
DOB of CF Patient

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Post Code
Email address of person being listed for transplant

Confirmation Emailexample@example.com
Mobile Number

Phone Number
Type of transplant
Eg lungs, liver, kidneys etc.
Details of person completing this form (if different from above)

Name

Street Address Line 2

Relationship

Mobile Number
Email address of person completing the form

Confirmation Emailexample@example.com
BANK ACCOUNT DETAILS FOR PAYMENT OF FUNDS
Bank account holder*
Name
BSB*
Account Number*
Relationship to member with CF*
Eg self , parent, spouse etc.
DECLARATION

I declare that all information I have provided to Cystic Fibrosis Tasmania is true and accurate. I understand if it is found that I have knowingly provided false or inaccurate information I may no longer be eligible to be a member, or receive any or all of the services and benefits provided by Cystic Fibrosis Tasmania.

I also authorise Cystic Fibrosis Tasmania to contact any health professionals to verify the information provided in this application.
E-Signature Name*
Date*

DayMonthYear
Date
Should be Empty:

TRANSPLANT ASSISTANCE APPLICATION FORM

We appreciate that the costs of undergoing a transplant can be large, especially for the extended period of time you are likely to be interstate. Please complete this form to apply for CFT's Transplant Assistance.

Eligibility: