SOUTHWEST FLORIDA
ASSISTANCE REQUEST FORM
(Full-Time Southwest Florida residents only)
Read all information/requirements carefully before printing form or completing form at bottom of page.
PLEASE SUBMIT APPLICATIONS 4 BUSINESS DAYS
PRIOR TO APPOINTMENT.
Assistance is provided for cancer screenings, associated testing, and medical item costs only, for individuals with/without insurance or those who cannot afford their deductible/coinsurance related to these tests. Applicants must be a United States citizen (with Social Security Number) and a full-time resident of Charlotte, Collier, or Lee Counties in Southwest Florida. Financial information may be requested during the decision making process and if requested must be provided prior to the scheduled test date. We do not provide financial assistance for surgical procedures, prescription medications, mortgage/rent, travel, fuel, food, utilities or other household/personal expenses. Assistance requests may only be submitted for one (1) facility/procedure/physician. Ancillary costs charged by outside providers (ie: labs, pathology) are the patient's responsibility.
Applicants may only request Assistance once per 12 month period.
There is a maximum limit of $400 per patient for the following assistance requests:
Cancer Screenings (ie: Mammogram, Lung screenings etc.), Diagnostic Mammogram, Ultrasound, CT, MRI, and other diagnostic imaging.Medical Supplies There is a maximum limit of $1,500 per patient for the following assistance requests:Additional non-surgical cancer testing procedures (biopsy, etc.)Genetic testing (for cancer diagnosis only)All requests will be reviewed on a case-by-case basis for approval. Requested amount is dependent on availability of funds and may not be available each month. Requested amount may be approved as submitted, denied, or adjusted based upon funds available, and insurance coverage. Approval of funds will be awarded without regard to race, national origin, gender, sexual orientation and may be suspended at any time due to unavailability of funds. Assistance requests for "past" medical screenings/tests/procedures, etc. will not be considered.
All information requested must be included or application will not be considered
Individuals without insurance will be given first priority.
Approved funding will be paid directly to testing facility and applied directly to patient's account. Prescription for screening/testing is required.
All patient personal and financial information will be kept confidential. Generic demographic information may be used in reporting outcomes of assistance program. PLEASE SUBMIT APPLICATIONS 4 BUSINESS DAYS PRIOR TO APPOINTMENT.
Patient/Parent Authorization/Acknowledgement: By clicking the "SUBMIT" button below I authorize 4 Words Foundation, Inc. to obtain and discuss information related to this request with my physician and other care providers/facilities. I certify the below statements are true. I acknowledge that payment is dependent on approval and availability of funds. All information related to this request will be kept strictly confidential and will not be shared with outside persons or agencies. All on-line requests will be responded to within 72 hours with either a request for additional information or an acknowledgement of receipt and review. I further acknowledge that failure to receive such communication means it was not received by 4 Words Foundation, Inc.. I also understand that 4 Words Foundation, Inc. may request additional documentation (ie: proof of insurance/non-insurance, financial information, and other personal information, etc.) in order to make a decision on the approval and distribution of funds requested. If requested to provide additional documentation or personal information I understand that I must provide the requested information within 10 days of request and prior to the scheduled test date or request for financial assistance may be denied.
GENERAL RELEASE and TERMS OF ACCEPTANCE: I hereby release, defend, indemnify, and agree to hold harmless 4 Words Foundation, Inc., its officers, directors, agents, sponsors, medical advisors, volunteers, and employees (if any) from all claims, demands, causes of action, present or future, whether known, anticipated or unanticipated, resulting from, arising out of, or incidental to my participation in the programs or benefits provided by the 4 Words Foundation, Inc.
For this request for financial assistance, I warrant the truthfulness of the information provided in this application.
