Patient and Caregiver Grant Application Process

Patient Grant Application

Date

YYYY

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Date of Birth

YYYY

Age

Type of Cancer

Stage of Cancer

Date of Cancer Diagnosis

YYYY

Race / Ethnicity

How did you learn about this grant?

Which of the following describes your employment or work situation?

(Check all that apply.)

Do you have health insurance?

Yes

Personal Statement

Who is Writing this statement?

If the applicant is unable to write his/her own statements, a nominating individual can write on his/her behalf. Please state name and reason for nominee.

Please describe how your cancer diagnosis has impacted your life.

What are your interests, hobbies, preferred activities? What activities would make you feel livelier, positive, and in-control while undergoing treatment?

Signature

I have read the application instructions and application and discussed them with my healthcare professional. I understand the purpose of the Seas It Patient & Care-giver Grant and fully accept all terms and conditions of the fund, and all other rules, regulations and conditions set forth concerning the grant. I hereby certify that the information provided in all parts of this application is truthful. I understand that any misrepresentation or false answer can be grounds for elimination from this program.

Date

YYYY

Signature

I understand that my health care provider may need to be contacted regarding the accuracy of the information provided and to verify my diagnosis. I give permission to the Seas It Patient& Caregiver Grant committee to contact my health care provider, understanding that the information obtained from my health care provider will not be shared with other parties, and is solely acquired for the purposes of fulfilling the grant.

HIPPA Authorization Form

Entering your name and name of the healthcare provider in the areas below grants your healthcare provider to disclose the following protected health information to Seas It.

Applicant Name

First Name

Last Name

Information to be disclosed:

(check all that apply)

Medical Provider Name

First Name

Last Name

Prefix

Suffix

Medical Provider Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical Provider Phone

(###)

###

####

Medical Provider Email or Fax

This protected health information is being used or disclosed for verification of cancer diagnosis and treatment status, in order to qualify for the Seas it Patient & Caregiver Grant.

This authorization expires on:

Fill in date six months from application completion.

YYYY

Seas It is not a health care provider or health plan covered by federal privacy regulation, and the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations. If disclosed, information would be disclosed only to entities and individuals associated with the Seas it Patient & Caregiver Grant. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment from your physician(s), or educational services or information from Seas it. You may inspect or copy the protected health information to be used or disclosed under this authorization. You may revoke this authorization in writing at any time by sending written notification to Amanda McGovern.

Signature of Participant or Personal Representative

Date

YYYY

Printed Name of Participant or Personal Representative

Description of Personal Representative’s Authority

(ex.: Power of Attorney)

Caregiver Grant Application

Date

YYYY

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Use the best number (mobile or landline).

(###)

###

####

Date of Birth

YYYY

Race / Ethnicity

How did you learn about this grant?

Which of the following describes your employment or work situation?

(Check all that apply.)

Personal Statement

Who is Writing this statement?

If the applicant is unable to write his/her own statements, a nominating individual can write on his/her behalf. Please state name and reason for nominee.

Please describe how this cancer diagnosis has impacted your life.

What are your interests, hobbies, preferred activities? What activities would make you feel livelier, positive, and in-control while being a caregiver? Think of anything that might keep your spirits up and allow you to carve out some time for yourself.

Patient Name

The person you are taking care of.

First Name

Last Name

Patient's Type of Cancer

Stage of Cancer

Date of Cancer Diagnosis

YYYY

In Active Treatment?

Yes

Medical Provider Name

First Name

Last Name

Prefix

Suffix

Medical Provider Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical Provider Phone

(###)

###

####

Medical Provider Email or Fax

This protected health information is being used or disclosed for verification of cancer diagnosis and treatment status, in order to qualify for the Seas it Patient & Caregiver Grant.

Signature of Participant or Personal Representative

Date

YYYY

Printed Name of Participant or Personal Representative

Relationship to Person Applying for Assistance

Doctor

Nurse

Social Worker

Case Worker

Other

Instructions

Step 1.

Fill out the Patient or Grant Application.

Step 2.

Seas It will review your application. Recipients of the goods, services and funds offered by Seas It will be selected on a first come, first serve basis without discrimination on the basis of gender, race, religion, ethnicity or sexual orientation.

Step 3.

Once the application is received and accepted, a Seas It representative will contact you to discuss the activity of your choosing.

Step 4.

Seas It will provide administrative support to set up the activity, including phone calls, paperwork, and meeting times. Seas It also will provide funds for equipment required for the activity, classes, and/or membership fees (often in conjunction with resources donated by the activity provider).

Patient and Caregiver Grant Application Process

Instructions

Step 1.

Step 2.

Step 3.

Step 4.

Contact Us

Our Mission

Instagram

Learn More

Seas It

Testimonials FAQ Contact Us