Smsf applicaton

SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688 Phone: (707) 469-9909 Fax: (707) 320-0018 Website: CLIENT APPLICATION FORM
Candidates for financial assistance must have been diagnosed with breast cancer, and must have a treatment plan and be pursuing that treatment plan or recovering within 2 months of the end of the treatment plan. If you have a diagnosis of metastatic breast cancer, are undergoing any form of treatment, and the disease or treatment prevents you from working, you may be considered eligible for If you have completed surgery, chemotherapy, and/or radiation for primary breast cancer, are considered to have no evidence of disease (NED), and are now taking adjuvant Tamoxifen, Arimidex or similar hormonal treatment on a long-term basis, you are no longer considered to be in treatment for active breast cancer and are no longer eligible for assistance. If you stop treatment for any reason against your oncologist’s advice, you will no longer be eligible for assistance.
Thank you for applying to Solano Midnight Sun Foundation (SMSF). Please read the following instructions before beginning the 1. Complete pages 2-5 of the application. Be as specific as possible with regard to income and expenses, savings, and other forms of assistance to which you may have access. Please initial the bottom of every page where indicated.
2. Pages 6 and 7 are two copies of an authorization for release of your medical information by your doctor. Fill this form out completely, and give one copy to your doctor (oncologist, surgeon - whomever you consider to be the head of your medical team). This form tells your doctor that you give him/her permission to provide information about you to SMSF and should be kept in your file. Please send one copy to SMSF along with your application.
3. Have your physician complete page 7, which will tell SMSF about your breast cancer diagnosis and treatment plan. He/she may complete the form and return it to you, or complete it and mail it directly to SMSF.
4. Submit your application to SMSF by mail or fax. Please note: Your application will not be processed until complete, including receipt of the physician report (page 7).
CRITERIA FOR ELIGIBILITY
ovides support for
individuals living in Solano County who ar
ovides support for
e going thr
individuals living in Solano County who ar
e going thr
east cancer
east cancer eatment, and whose
income and/or expenses ar
income and/or
e significantly impacted by tr
expenses ar
eatment. SMSF
e significantly impacted by tr
eatment. SMSF eserves the right to verify income, expenses, and
treatment plan by r
equesting the following information.
eatment plan by r
VERIFICATION
CONDITIONS
Identification
Must provide proof of identification. Picture ID, CDL, California ID, passport, employment or school ID, or other acceptable identification and social security card.
Must be a resident of Solano County to be eligible for SMSF support. Proof of location of residence by rent receipt, mortgage payment receipt or contract, or note from landlord; utility receipts, turn-off notice, late notice, eviction notice, fore-closure notice, 3 day notice to quit, etc.
Must provide verifiable income information for pre-treatment and during treatment. Earned and unearned income for spouse or other responsible persons living in the home.
Medical statement
Must be in active treatment to receive SMSF support. Current diagnosis, prognosis, surgery date, and treatment plan with date and signature of treating physician Non-shelter expenses
Must provide information about credit payments, car payments, child care, child support, cable, furniture storage, health club, other legal obligations for spouse or other responsible persons living in Vehicles
Personal Items
Real estate
**Please initial the bottom of every page of this application**
Date of Application
SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688 Phone: (707) 469-9909 Fax: (707) 320-0018 Website: DEMOGRAPHIC INFORMATION
Name:
Address: City, State Zip: Phone number: Home: MARITAL STATUS (please circle)
1. Married
CHILDREN
Name
SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688 Phone: (707) 469-9909 Fax: (707) 320-0018 Website: What medical insurance do you have? (Private, Medicare, MediCal, BCCTP, etc.) Current breast cancer diagnosis – please include stage and treatment plan (in your own words) Tell us your reasons for making this application: Did someone help you with this application?  No  Yes Name: Please list your physicians below, including name and phone number:Medical Oncologist: Please provide us with an emergency contact. The person you list should be someone that you are in contact with on a regular (daily or weekly) basis that we can call if we are unable to reach you.
Name: Please use this space to add any comments or information you would like to tell us: SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688 Phone: (707) 469-9909 Fax: (707) 320-0018 Website: WORK HISTORY
Most recent employer:
If not currently working, date last worked: CURRENT INCOME
Monthly amount
Please indicate if you have applied for any of the following.
Please indicate if you have applied for
Circle “accepted” if you ar
cle “accepted” if you ar eceiving funding, “pending” if your
application is in pr
eceiving funding, “pending” if your
ocess, or
application is in pr
ocess, or
“denied” if you have been denied for that pr
“denied” if you have been denied for
8.In-home care/In-Home Supportive Services TOTAL AVAILABLE MONTHLY INCOME (add lines 1-22 together):
SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688 Phone: (707) 469-9909 Fax: (707) 320-0018 Website: Are you receiving funds/loans/donations, etc. from any other social services agencies in your County?  No  Yes If yes, list all agencies and dates and amounts of last aid (use a separate sheet if necessary): __________________________________________________________________________________________________ __________________________________________________________________________________________________ MONTHLY EXPENSES
1. Medications (related to breast cancer treatment only) 1. Medical co-payments and/or share of cost 1. Other:
TOTAL OF ALL MONTHLY EXPENSES (Add lines 1 through 17 together):
Please check this box if you would like to be referred to other agencies for possible assistance. Referrals may result in sharing your information between SMSF and other agencies.
By signing below, I agree that the above information is true and correct.
APPLICANT AUTHORIZATION FOR
RELEASE OF INFORMATION
SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688 Phone: (707) 469-9909 Fax: (707) 320-0018 Website: Agency/Individual From Whom Information is Requested (e.g., your physician)
hereby authorize you to release to Solano Midnight Sun Foundation, non-profit organization (20-8124921) specific information requested by them which I cannot provide concerning: This information is needed to determine my eligibility for assistance from Solano Midnight Sun Foundation (SMSF) I have read this form and have agreed to its request prior to my signing.
Note: Provide this form to the physician or other agency from whom you are requesting the release of information to
Solano Midnight Sun Foundation.
SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688 Phone: (707) 469-9909 Fax: (707) 320-0018 Website: APPLICANT AUTHORIZATION FOR
RELEASE OF INFORMATION
Agency/Individual From Whom Information is Requested (e.g., your physician)
hereby authorize you to release to Solano Midnight Sun Foundation, non-profit organization (68-0354961) specific information requested by them which I cannot provide concerning: This information is needed to determine my eligibility for assistance from Solano Midnight Sun Foundation (SMSF) .I have read this form and have agreed to its request prior to my signing.
Note: Provide this form to the physician or other agency from whom you are requesting the release of information to Solano
Midnight Sun Foundation.
SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688 Phone: (707) 469-9909 Fax: (707) 320-0018 Website: PHYSICIAN REPORT
The individual listed below has requested assistance from Solano Midnight Sun Foundation (SMSF) and has stated that s/he is unable to work or is unable to work at pre-treatment level. A signed release for the requested information is attached.
Please complete this form and return it by: ____________ (date) Attn: Director of Client Services
Solano Midnight Sun Foundation
795 Alamo Drive, Suite 106
Vacaville, CA 95688
SECTION I
SECTION II – T
SECTION II – O BE COMPLETED BY
O BE COMPLETED BY YOUR PHYSICIAN
Pertinent pathology results (attach copy of report if available): Is patient’s condition suitable for
Is patient’
employment?
s condition suitable for
employment? Y
What level of employment activity is suitable for patient?
What level of employment activity is suitable for
patient? Part-time ____ hours per week 
Projected date patient can r
eturn to work at pr
ojected date patient can r
eturn to work at pr
eatment level:
Planned surgeries – list date and expected date of recovery:
Planned surgeries – list date and expected date of r
Other planned tr
eatments (chemo, radiation, etc.) – list pr
planned tr
ojected end date:
eatments (chemo, radiation, etc.) – list pr

Source: http://solanomidnightsun.org/wp-content/uploads/2011/10/SMSF-Applicaton.pdf