Leukemia Texas Patient Aid Application

Application Deadline: Friday, March 15th, 2019

WRITTEN NOTIFICATION OF THE STATUS OF YOUR APPLICATION WILL BE SENT WITHIN SIX (6) WEEKS OF THE ABOVE DEADLINE
Patient Information
Confirmation will be e-mailed to this address.
(patients are only eligible to receive aid once per 12 months)
Do you have any of the following (check all that apply)
Medical Insurance
Prescription Drug Plan
Medicare
Medicaid
None
If patient is a minor, Legal Guardian to complete
Attestation of Ongoing Care
A Patient Aid grant, up to $1,250, is requested from Leukemia Texas for the purpose of ensuring equal access to care which includes: treatments, laboratory testing, physician examinations, counseling and psychosocial support, transportation, and housing for the patient.

The information provided will be verified with the patient’s physician, nurse and/or social worker by a staff member of Leukemia Texas.

Disclaimer: The Attestation of Ongoing Care requires the information of two people from the physician’s office or clinic. Examples, physician, physician assistant, nurse, social worker, financial counselor or other admin within the office.
Treatment Status:

(Check all that apply)
Initial Treatment
Relapse
Maintenance
Remission
Clinical Trial/Experimental Treatment
Physician Name and Contact Information
Other Contact from physician’s office or clinic (Social Worker, Nurse, Physician Assistant, etc.)
Additional Information
Describe the circumstance supporting your request for financial assistance
Do you plan on using your assistance for any of the following (check all that apply):
Medical Bills
Mortgage/Rent
Utilities
Vehicle/Transportation
Other
If YES, please provide your home address prior to treatment.
Patient Certification
I authorize Leukemia Texas and its agents to access and review the information I have submitted herein, including any private or confidential health information. I understand that Leukemia Texas intends to use this information in connection with their assessment of patient aid and potential payment of patient aid and will not disclose this information to third parties. This authorization expires one year from the date of submission, unless otherwise agreed.
By checking this box, I hereby authorize the release of information in this application and related to my diagnosis to Leukemia Texas for the purpose of seeking financial assistance. I affirm that all of the information provided in order to qualify for financial assistance is complete and accurate. I understand that I may be denied assistance if any of the above information is false, and that I may be required to repay any assistance that I have received based on false or incomplete information.

I understand and agree that:
  1. Leukemia Texas in its sole discretion shall determine my eligibility, participation and termination in its Patient Aid program;
  2. Leukemia Texas does not guarantee payment of patient aid;
  3. Leukemia Texas shall have no liability pursuant to my application, participation, continuation or termination in its Patient Aid program;
  4. I authorize my Physician to release to Leukemia Texas such medical information of mine as it may require to administer my application and participation in its Patient Aid program;
  5. I authorize Leukemia Texas to run a background check.
Photo Consent (Optional)
*You may submit your photograph for Leukemia Texas office use.
Please send your file to: patientaid@leukemiatexas.org
By checking this box, I hereby consent to the use of my photographic image together with my name, age, city of residence, occupation, and type of leukemia for public use by Leukemia Texas, Inc. I further release from liability and hold harmless Leukemia Texas, Inc. in the use of my image and information.
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