| PATIENT
INFORMATION |
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|
Date
|
|
| name |
last:
MI:
first: |
| address |
|
| city |
|
| state |
|
| zip |
|
| telephone |
|
| sex |
|
|
Social
Security #
|
|
| email |
|
|
Date of Birth |
|
|
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|
School
or Employer |
|
| address |
|
| city |
|
| state |
|
| zip |
|
| business telephone |
|
|
name
of employee benefits administrator at place of employment |
telephone |
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|
Is
patient aware of his/her condition? |
|
|
|
Complete
if Patient is a Child or Dependent |
|
|
| mother /
guardian name |
last: MI:
first: |
| address |
|
| city |
|
| state |
|
| zip |
|
| telephone |
|
| email |
|
| occupation |
|
|
Employer |
|
| address |
|
| city |
|
| state |
|
| zip |
|
| business telephone |
|
|
name
of employee benefits administrator at place of employment |
telephone |
|
|
| father /
guardian name |
last: MI:
first: |
| address |
|
| city |
|
| state |
|
| zip |
|
| telephone |
|
| email |
|
| occupation |
|
|
Employer |
|
| address |
|
| city |
|
| state |
|
| zip |
|
| business telephone |
|
|
name
of employee benefits administrator at place of employment |
telephone |
|
|
List
Family Members and Ages of All Children |
|
Name |
Age |
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| Brief
Medical History of Patient (TO
BE COMPLETED BY ATTENDING PHYSICIAN) |
|
USE
CONTINUATION SHEETS WHERE NECESSARY |
|
|
date
of diagnosis
|
|
|
diagnosis
|
|
|
physician's
name
|
last: MI:
first: |
| address |
|
| city |
|
| state |
|
| zip |
|
| telephone |
|
|
Social
Security #
|
|
| license # |
|
|
DEA
#
|
|
|
attending
physician's signature |
(required)
|
|
|
| I
HEREBY AFFIRM, UNDER THE PENALTIES OF PERJURY, THAT I DO NOT HAVE
AVAILABLE INSURANCE COVERAGE, THE REQUISITE MEANS, OR ANY OTHER SOURCE
OF REIMBURSEMENT FOR THE AMOUNT FOR WHICH I SEEK ASSISTANCE.
I ALSO CERTIFY THAT ALL THE INFORMATION PROVIDED ON THIS
APPLICATION IS TRUE, AND THAT THE PATIENT AID COMMITTEE OF THE
NATIONAL LEUKEMIA RESEARCH ASSOCIATION HAS THE RIGHT TO TERMINATE ANY
OR ALL ASSISTANCE TO THE PATIENT UPON PERIODIC REVIEW OF THE
CASE, IF NECESSARY. |
|
signature of patient
or responsible adult |
(required)
|
|
address & phone # |
|
|
|
| MEDICAL
INSURANCE PLAN |
|
Name
of
Policyholder
|
last: MI:
first: |
|
Name of Insurance Company
|
|
| telephone |
|
| address |
|
| city |
|
| state |
|
| zip |
|
|
policy
#
|
|
|
Insurance
Co. Representative |
|
|
telephone
|
|
|
amount
of deductible
|
family $ indiv. |
|
|
Co-Insurance
(% split e.g., 80-20, 60-40 |
|
| Other
Supplement (non-governmental) Insurance |
|
|
Medicare
/ Medicaid |
|
Is
patient enrolled in MEDICARE? |
MEDICARE
claim # |
|
Is
patient enrolled in MEDICAID? |
MEDICAID
claim # |
|
Is
a MEDICAID card used to help with prescriptions? |
|
|
Co-Insurance
(% split e.g., 80-20, 60-40) |
|
|
Do
you belong to a drug prescription plan?
|
|
| If
yes, complete the following |
|
|
Insurance
Co. Representative |
|
|
telephone
|
|
|
member
ID #
|
|
|
Is
the patient a veteran of the United States Armed Forces?
|
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|
Other
Assisting Agencies (e.g., American Cancer Society, etc
|
|
|
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|
Social
Worker Name |
|
|
telephone
|
|
|
affilliation |
|
|
|
|
Who
referred you to National Leukemia Research Association?
|
|
|
|
signature of patient
or responsible adult |
(required)
|
|
address & phone # |
|