UCSF “Just 4 U” Support Package Application Information and

6700 Baum Drive Suite 8 Knoxville, TN 37919 www.UnitedCSF.org P. (865)-474-1551 E. [email protected]
UCSF “Just 4 U” Support Package Application Information and Instructions
Dear Cancer Patient and Family,
United Cancer Support Foundation is a dedicated cancer nonprofit organization. One of our
programs, “Just 4 U” Support Package, is designed to support cancer patients with gifts that provide
relaxation and distraction during cancer treatment. Cancer is a dreadful disease that affects those
suffering from it physically and emotionally. The goal of this program is to help the cancer patient reduce
stress, which will have a positive impact during treatment.
To complete the application process, cancer patient will need to fill out the application form and
the diagnosis verification form that must be signed by a medical professional and mail the form to: Patient
Support Department 6700 Baum Drive Suite 8 Knoxville, TN 37919 or send email attachment to:
[email protected]. Once we have received the completed forms, we will process and verify the
information in the forms. Then, our staff from Patient Support Department will start assemble and send
you the personal support package.
God Bless,
Patient Support Department
United Cancer Support Foundation
6700 Baum Drive Suite 8 • Knoxville, TN 37919 Phone: 865-474-1551 E-mail: [email protected]
APPLICATION FOR ASSISTANCE
PATIENT INFORMATION FORM
Patient’s First name:
Middle:
Last name:
Birth date: ____/_____/_____
Age:
Sex: □ M
Home address:
City:
Phone No.:
State:
ZIP code:
*Signature:
E-mail:
How did you hear about our program?
□ Family
□Friend
How many people are in your household?
□F
□Callers
□Other (specify):
Estimated annual household income:
*Under penalty of perjury, I declare that I have examined this form, including any accompanying statements and
schedules, to the best of my knowledge; it is true, correct, and complete.
VERIFICATION FORM
THIS PORTION MUST BE COMPLETED BY A MEDICAL PROFESSIONAL ONLY
Medical Professional:
Title:
Office address:
City:
State:
ZIP code:
Phone No.:
EIN/FEIN:
Cancer type and stage:
On remission?:
□ Yes □ No
E-mail:
Active treatment:
When is the next appointment:
Comments:
Verification of Cancer Patient:
____________________________
__________________________
Medical Professional Signature*
Date (MM/DD/YYYY)
*Under penalty of perjury, I declare that I have examined this form, including any accompanying statements and
schedules, to the best of my knowledge; it is true, correct, and complete.
EMERGENCY CONTACT PERSON OR GUARDIAN (OPTIONAL)
Contact Name (first, last):
Relationship to patient:
X ___________________________
Contact Signature
Home phone:
(
)
Work phone:
(
)
_________________________
Date (MM/DD/YYYY)
For more information, please visit our website @ UnitedCancerSupportFoundation.org
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APP-2016
MEMORANDUM OF UNDERSTANDING
This MEMORANDUM OF UNDERTANDING is entered between UNITED CANCER SUPPORT FOUNDATION
(hereinafter “UCSF”), located at 6700 Baum Drive Suite 8 Knoxville, TN 37919 and PATIENT:
Name
Last name
___
whose address is
___
PARTIES
1.
2.
UCSF is a nonprofit tax exempt organization described in Section 501(c) (3) of the Internal Revenue Code. The
primary purposes for which UCSF was formed is to support cancer patients and their families through its
distribution program to distribute assistance funds and commodities; to advocate healthy eating and provide
educational initiatives for cancer awareness prevention.
PATIENT: name
last name
is a natural person.
RECITALS
3.
4.
UCSF, as one of its charitable programs, provides support to cancer patients and their families through its relief
funding programs.
Name:
is a cancer patient.
TERMS OF AGREEMENT
Now, therefore, in consideration of the foregoing and mutual promises and covenants contained herein, the
parties agree as follows:
5.
6.
7.
8.
9.
UCSF, at its discretion, agrees to provide PATIENT with assistance for the purposes of supporting cancer patients
and their families. UCSF agrees to provide the PATIENT with supplies or services and PATIENT agrees to use these
supplies or services specifically to support the cancer patient and/or his/her family.
PATIENT agrees to provide to UCSF a narrative description of how this contribution, as well as any additional
assistance provided by UCSF, was used, at any reasonable request made by UCSF.
PATIENT agrees to provide UCSF permission to use his/her information, including pictures and testimonials, for
verification or any other purposes at UCSF’s discretion.
PATIENT agrees that any changes in treatment status will be reported to UCSF.
PATIENT understand that when cancer is in remission this means the end of the services.
VERIFICATION
I declare under penalty of perjury subject to all applicable laws that I have carefully reviewed the MEMO OF
UNDERSTANDING and verified that that all the information provided is true and correct to the best of my knowledge.
X ___________________________
Patient/Guardian Signature
_________________________
Date (MM/DD/YYYY)
“Just 4 U ” Support Package
Please check the ones that you like. Each applicant is allowed to
pick 5 favorite items from the list below.
Board games
Tabletop Herb Garden
Puzzle Books
Cross stitches
Jigsaw Puzzles
Coloring Books
Other (depends on availability)
Regal Cinemas Gift Card
________________
United Cancer Support Foundation
6700 Baum Drive Suite 8 Knoxville, TN 37919 www.UnitedCSF.org P. (865)-474-1551 E. [email protected]