Application for Financial Assistance:

About the Transportation Assistance Fund

This fund helps with transportation costs for a child and caregiver to get to and from treatment. Limited lodging may be considered when other non-profit lodging is unavailable.

About the Emergency Assistance Fund

Families who have a child who has been inpatient for 15 consecutive days (or away from home for 15 consecutive days to receive treatment) during the past 90 days are eligible to receive $300 in emergency assistance, which may be provided per year to help families offset expenses. Assistance may be used for mortgage, rent, utility payments, child care, health insurance premiums, car expenses, or treatment-related expenses (such as meals away from home, prescriptions, and parking).

Financial Aid Form

Child/Patient Information
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Parent/Guardian Information
If guardians do not reside in the same household and both are seeking financial assistance, both guardians must fill out separate applications.
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Medical Information
A letter from child’s hospital social worker or other hospital professional explaining the child’s diagnosis, family situation, treatment plan for the next 60 days and the assistance being requested is needed in addition to completing this section. Health providers are reminded that they must comply with the HIPAA requirements when presenting NCCS with patient information.
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*A doctor’s letter documenting the child’s diagnosis and grade is required for children diagnosed with a glioma, ependymona or astrocytoma. The NCCS reserves the right to request a doctor’s letter when deemed necessary.
Household Income
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Banking
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Please list your checking/savings and other easily accessible accounts in the space provided. Include any fundraising accounts that have been established on behalf of your child. Copies of your most recent statements for all of the accounts below must be included. Remember, you must have less than $5,000 in easily accessible accounts to be eligible for assistance.
Insurance Information
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Funding Procedures
1. A case manager will contact you by phone once the application has been received and processed by the NCCS to determine how we can best assist you.
2. Transportation assistance may be provided for up to 60 days. Financial assistance is not retroactive. In order to request additional transportation assistance, you must have a hospital professional submit a request in writing that provides an update on your child’s treatment plan. (You do NOT need to submit a new application.)
Assistance Requested
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Consent to Release Information and Affirmation
I do hereby authorize all hospitals, financial institutions and insurance groups to release to the NCCS, or its duly authorized representative, any information deemed necessary to complete its investigation of my application for financial assistance. I further authorize the NCCS and its representatives to provide such information to those institutions as may be reasonably required to assist our family and our child. All consents given herein shall continue until such time as the undersigned provides notice of termination in writing.
The "undersigned" means the parents or guardians of the child. The undersigned acknowledge(s) and agree(s) to:
* 1. The undersigned are the parents or guardians of the child.
* 2. Financial assistance will be provided with the use of said funds to be specified by NCCS.
* 3. The undersigned further agree(s) to return any unused funds immediately to the NCCS so that those funds can be utilized by the organization to benefit other families.
* 4. The undersigned acknowledges(s) and agree(s) to maintain records that will be made available to the NCCS upon reasonable request, detailing the expenditures made from the funds provided by the organization.
The NCCS will pursue restitution for grants if it is determined that the information submitted on the application is false. I have read the guidelines for financial assistance and the eligibility checklist and I declare that the information furnished on this application form, including attached sheets, is true and correct to the best of my knowledge.
Furthermore, the undersigned does hereby give continuing consent to NCCS to use images of any and all kinds of my child, myself, and our names, so long as they are only used on behalf of NCCS.
I have read the guidelines for financial assistance and the eligibility checklist, and I declare that the information furnished on this application form, including attached sheets, is true and correct to the best of my knowledge.
As the undersigned, I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.
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*We can only speak to the parent(s)/guardian(s) that have signed this application.
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*Anti-Discrimination Policy: You and your child will not be discriminated against or denied assistance because of your race, religion, ethnicity, national origin, gender, sexual orientation, or political affiliation. All financial applications will be reviewed on a case-by-case basis and final determination will be made based upon your eligibility, NCCS guidelines and the availability of funds.