HERE - Kellie`s Krew

Kellie’s
Krew
Patient Assistance Application
DATE
contact information
Mr
Mrs
Miss
Please attach a
current photo
of the applicant
Ms
Dr
M M D D y y y y
Other
First Name
Last Name
Street Address
City
State
Telephone
Zip Code
Home
Cell
Business
E-mail Address
Preferred method of contact
Phone
E-mail
Post
Please answer the following questions as accurately as possible
1
2a
Q: Please tell us about your cancer medical history. Include primary diagnosis, locations, origin of tumor, and dates.
Please be as specific as possible.
Q: Has your cancer metastasized
Yes
2b
Q: If yes, where?
No
3
Q: Previous treatment (chemotherapy, radiation, other):
4
Q: Future treatment (chemotherapy, radiation, other):
6
Q: Have you lost time from your place of employment?
Please identify treatment facility, chemotherapy drug regimen, and/or number of radiation treatments
Please identify treatment facility, chemotherapy drug regimen, and/or number of radiation treatments
Yes
7
No
Q: Please tell us anything else that you would like to share:
Kellie’s Krew, Inc. strives to help as many applicants as possible from the funds raised through our events and donors.
Please be aware of the following guidelines when applying for assistance from Kellie’s Krew:
• All applicants must be undergoing treatment at the time of and during the month of requested assistance.
• Applications must be submitted on or before the 15th of each month to be considered for assistance in the following month.
• Applicants must reapply each month to continue receiving assistance. Any assistance beyond two months will require further documentation.
• The Kellie’s Krew Patient Assistance Program is limited to $100 per month, and will be provided in the form of a Visa/MasterCard gift card.
• The Kellie’s Krew Board of Director’s reserves the right to deny applications based upon funds availability, or other circumstances that may arise.
• Kellie’s Krew Inc., does not discriminate against any person on the basis of race, color, national origin, disability, gender, gender identity, sexual
orientation, religious preference, or age in its programs, services, assistance programs and activities.
• We value your privacy, therefore applicant information and medical history will only be shared with the Kellie’s Krew Board of Directors unless prior
consent is obtained.
• Please submit your application by email or by mail to:
[email protected] -or- Kellie’s Krew, Inc.
c/o Patient Assistance
111 S. Railroad Ave.
Dunn, NC 28334
Name:
Date:
(Please sign and date your application)