Patient Application - American Association of Cancer Support

322 Nancy Lynn Lane Suite# 3 Knoxville, TN. 37919: www.AmericanCancerSupport.org P. (865)-240-3116 F. (865) - 240 -3183
The Official Application Information and Instructions
Dear Cancer Patient and Family,
American Association for Cancer Support, Inc. is a dedicated cancer nonprofit organization. One
of our programs, Cancer Patient Support Program, is designed to support cancer patients with available
funds or supplies. Cancer is a dreadful disease that affects those suffering from it physically and
emotionally. It is our goal to help relieve the patients and families’ hardships.
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 Service Department 322 Nancy Lynn Lane Suite# 3 Knoxville, TN. 37919 or send email
attachment to: info@AmericanCancerSupport.org. Once we have received the completed forms, we will
process and verify the information in the forms. Then, our Service Support Department will start to
prepare your “Cancer Care Package” or “Cancer Care (visa) Card” depends on availability.
God Bless,
Patient Support Services
American Association for Cancer Support, Inc.
322 Nancy Lynn Lane Suite 3 • Knoxville, TN 37919 Phone: 865 240 3116 E-mail: info@AmericanCancerSupport.org
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:
Phone No.:
EIN/FEIN:
On remission?:
Active treatment:
□ Yes □ No
Verification of Cancer Patient:
____________________________
Medical Professional Signature*
State:
ZIP code:
Cancer type and stage:
When is the next appointment:
__________________________
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.
Comments:
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 @ AmericanCancerSupport.org
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APP-2015
MEMORANDUM OF UNDERSTANDING
This MEMORANDUM OF UNDERTANDING is entered between AMERICAN ASSOCIATION FOR CANCER SUPPORT,
INC. (hereinafter “AACS”), located at 322 Nancy Lynn Lane Suite# 3 Knoxville, TN. 37919 and PATIENT:
Name
Last name
,
whose address is
PARTIES
1.
2.
AACS is a nonprofit tax exempt organization described in Section 501(c)(3) of the Internal Revenue Code. The
primary purposes for which AACS 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.
AACS, 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.
AACS, at its discretion, agrees to provide PATIENT with assistance for the purposes of supporting cancer patients
and their families. AACS agrees to provide the PATIENT with funds or supplies and PATIENT agrees to use these
funds or supplies specifically to support a cancer patient and/or his/her family.
PATIENT agrees to provide to AACS a narrative description of how this contribution, as well as any additional
assistance provided by AACS, was used, at any reasonable request made by AACS.
PATIENT agrees to provide AACS permission to use his/her information, including pictures and testimonials, for
verification or any other purposes at AACS’s discretion.
PATIENT agrees that any changes in treatment status will be reported to AACS.
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)