FISHING FOR THE FIGHT APPLICATION FOR ASSISTANCE

Date of Application*

Date

Name of Applicant*

APPLICANT'S Birthday*

Physical Address*

Mailing address*

Email*

example@example.com

Phone Number*

Country CodeArea CodePhone Number

Driver’s License Number*

How many years have you been a resident of Sublette County or LaBarge, Wyoming?

How many months out of each year do you reside in Sublette County or LaBarge, Wyoming full time?

Total Amount Requested*

Please describe the medical condition you are seeking assistance for:

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.*

Please explain the nature of your current needs. Specifically, what out of pocket expenses do you have which are not reimbursed or covered by any insurance? Examples are: travel related expenses incurred related to receiving treatment and costs of treatment not covered by insurance (if required by your treating physician.)

Additional pages may be supplied as necessary and mailed to

FISHING FOR THE FIGHT

PO BOX 1038

PINEDALE, WY 82941

Name of Treating Physician*

A signed statement from your current physician is required for all applicants. Physician statements may be emailed to BOARDFFF@GMAIL.COM OR mailed to:

Fishing for the Fight

PO Box 1038

Pinedale, WY 82941

Phone Number of Treating Physician*

Address of Treating Physician*

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.

Name*

Are you applying as a parent or guardian?*

ParentGuardianPatient (self)

If you are applying as a parent or guardian, please list your name below.

Signature*

If you have any questions about this application, please contact any Fishing for the Fight board member or email boardfff@gmail.com. All information in this application is kept confidential.

In order to be considered for assistance, you must submit: (1) this application; (2) a signed copy Fishing for the Fight’s HIPPA Policy; (3) a signed copy of Fishing for the Fight’s Travel & Expense Policy (4) a signed and dated physician/provider statement.

FISHING FOR THE FIGHT APPLICATION FOR ASSISTANCE

Certification