Decisions for financial assistance for the month of September will be delayed until September 30, 2014 you will receive the decision by end of day on September 30, 2014

 

The financial assistance program is a program that has been put in place to assist those with pancreatic cancer to help cover basic cost of living expenses. Due to the overwhelming response we have received for this program we are only able to provide assistance for necessary living expenses, please see below for more information on what we provide assistance for. 

Guidelines for Financial Assistance

PLEASE READ THE ENTIRE PAGE CAREFULLY BEFORE APPLYING.

Due to several requests for financial assistance please do not call regarding your application. If we have questions we will contact you. All correspondence is done through email and regular mail.   You are more than welcome to email us regarding the status of your application at rhonda@npcf.us

**Any inaccurate information on your application may result in disqualification to receive financial assistance

Assistance Program Purpose and Mission

The Assistance Program is made available to provide direct financial support for patients who are currently in treatment for pancreatic cancer. Our hopes are to make the days less stressful by helping with expenses faced during this difficult time.

Availability


Applicant must reside in the United States to be considered for assistance.
Each applicant may apply once a month up to 6 months total. *The committee reserves the right to distribute assistance amounts based on funds available at the time of request.

Support Summary
- Assistance is made available to both men and women diagnosed with pancreatic cancer through the NPCF Patient Assistance Program.
- You must be currently undergoing pancreatic cancer treatments to apply.
- The program is available due to the generosity of our donors and the volunteers that help with our fundraising events.

Policy

The policy is to guide the organization and its committee in processing requests from pancreatic cancer applicants who have completed the application for assistance with NPCF and have provided the proper documentation.

  1.  The Assistance Program has the right to have “open and closed” periods. If there is a period where the program is closed, notification will be done on this page of the website. * The website will serve as the official notice for the Patient Assistance Program.
  2. Each applicant may apply once a month, up to six months total.. *The committee reserves the right to distribute assistance amounts based on funds available at the time.

Requirements for Assistance

  1. Applicant must be a U.S. citizen
  2. You must live in the United States
  3. The application must be completed in full, including submitting all required documents.
*Original signatures, No faxes or copies of doctor signatures will be accepted.

Requirements to Apply

You MUST provide a copy of the following items

  1. Proof of US Citizenship. Copy of Birth Certificate or Passport.
  2. Copy of Drivers License or State Identification Card.
  3. A copy of your current income tax return – Page 1 showing proof of income.
* If you are not working, you must show proof of the household income.
* If you are only receiving social security – you must attach proof.
* If you are only receiving unemployment or medical disability – you must attach proof.
  4. Copy of a medical bill related to your pancreatic cancer treatment.
  5. A Doctor letterhead signed by treating doctor advising you are currently in treatment for pancreatic cancer.
*Must be an original signature by the doctor, not a copy or fax copy.
  6. Proof of current address if it differs from Driver’s license or ID card. i.e.: lease agreement or mortgage statement
  7. Provide copies of all outstanding bills you are requesting assistance with along with a letter of explanation**

**The following is a list of bills that will be considered through our financial assistance program

  • Rent/mortgage(mortgage can not be in foreclosure)
  • Phone (phone bills that include cable or internet will not be considered, a break down of the actual cost of the phone line is required)
  • Electric/Gas/Water bills
  • Grocery bills (can be reimbursed with copy of receipt submitted at time of request)
  • Moving expenses considered if downsizing due to financial hardship
  • Bills can not be on an automatic payment system with the creditor

 *Any misleading information provided in application will automatically terminate qualification for financial assistance*

When Will I Receive My Assistance

If you are approved for financial assistance, assistance will be sent to directly to the creditor 1 week from the date we receive your completed application.

Important Facts

  • You must be a US Citizen. Please do not apply if you cannot prove that you are a US Citizen.
  • Your application will NOT be processed or considered without the above requirements.
  • On occasion testimonials may be required by applicant at the approval committee’s request.
  • Policies and application criteria are reviewed periodically and amended accordingly.
  • We can’t accept applications from other organizations. You must submit the NPCF application.
  • We cannot process applications completed in a foreign language.
  • NPCF does not provide financial assistance for insurance company’s bills, hospital bills, co-pays, or collection accounts, credit cards, cable bills, or cell phone bills unless the cell phone is the main phone.
  • We do provide assistance for rent/mortgage, utilities, travel expenses for treatment, groceries, and other necessary living costs.
  • Financial Assistance is based on funds available at time of request and all criteria for guidelines must be met.
  • We will contact you if we have questions about your application. Please do not call regarding your application. You are more than welcome to email us regarding the status of your application at info@pancreaticcancerfoundation.com

TO APPLY

Please fill out the form below

Financial Assistance Application

First Name *

Last Name *

Address *

Address

City *

State *

Zip *

Email *

 Yes, this is my email as I am the patient. And the PRR will contact me only through email. No, I do not have an email address, but this is the preparer's email. I give you permission to communicate with the preparer.

Birth Date *

Phone Number *

U.S. Citizenship is required to apply for patient assistance. If you are not a U.S. Citizen you do not qualify for assistance. *

 I Am a U.S. Citizen I Am Not a U.S. Citizen

As a US Citizen to be considered, you agree to provide 1 of the following in Part 2 of the application: *

 US Birth Certificate- Copy US Passport - Copy US Citizen Naturalization Certificate-Copy

Is your primary language English or Other? *

Have You Previously Received Assistance from NPCF *

Did Someone Else Prepare This Form for You? *

Preparer Name

Preparer Title/Relationship

Preparer Email Address

Preparer Address

Preparer City

Preparer State

Preparer Zip Code

If Yes to Previous Assistance, When *

What is Your Diagnosis? *

By Checking "Yes" You Certify That You are a Patient Currently Undergoing Treatment for pancreatic cancer *

 Yes

Were You Referred to NPCf *

Referrer Name:

Referrer Organization:

Referrer Phone #:

Referrer Email Address:

Treating Oncology Physician's Name: *

Physician's Office Name *

Contact Name at Physician's Office

Physician's Address *

Physician's City *

Physician's State

Physician's Zip Code *

Physician's Email *

Physician's Phone No. *

Emergency Contact Name *

Emergency Contact Phone No *

Contact Person's Email Address *

Current Household Monthly Income: *

Do You Have Insurance? *

Insurance Company Name

Car Payment *

Mortgage/Rent Payment *

Total of All Other Bills *

Solely Responsible for Mortgage/Rent Payment? *

Medicaid: *

Medicare: *

Veteran Benefits *

Receive Additional Income Support? *

If Yes, Additional Income Amount

Additional Assistance, How do They Help?

Are you planning to move in the next 30 days or not be at the physical address you have given?: *

Please make sure you have provided an physical address and not a PO BOX #. Did you do this? *

 Yes

NPCF will send you an email that you must respond to before assistance will be mailed. Will you be able to respond to the email? *

 No

Would You Share Your Story? *


 

Co-Pay Relief / Prescription Assistance/ Health Insurance Premiums and other programs – Cancer Patients

PPA – Partnership for Prescription assistance

888-477-2669 / www.pparx.org

Description of support – offers access to more than 476 public and private patient assistance programs, including more than 150 programs offered by pharmaceutical companies – includes assistance for the uninsured.

Patient Access Network Foundation

866-316-7263 / www.panfoundation.org

Description of support – Assists patients who cannot access the treatments they need due to out of pocket health care costs including deductibles, co-payments and co-insurance.

Patient advocate Foundation’s Co-pay Relief program

866-512-3861 / www.copays.org

Description for support – provides direct co-payment assistance for pharmaceutical products – including Medicare part D beneficiaries who financially and medically qualify.

CancerCare

800-813-4673 /  www.cancercare.org

Description of support – Limited financial grants for transportation, homecare, childcare and pain medication.

CancerCare Co-payment Assistance Foundation

866-55-copay /  www.cancercarecopay.org

Description of support –Provides co-pay assistance for pharmaceutical products – must be US Citizen. Help for people with Health Insurance programs and can not afford co-pays.

Crafters for Chemo Copay Assistance

www.craftersforchemocopay.com/default.html