Patient Financial Assistance – Eligibility Criteria & Guidelines

hope abounds

Supporting women, teens, children and their families with cancer

APPLICANT GUIDELINES:
♦ North Carolina or Northeastern South Carolina resident who has been diagnosed with cancer and is in any phase of active treatment (recent surgery, chemotherapy or radiation.)
♦ Must be a US citizen and proof may be required.
♦ If Patient is under the age of 18, these requirements pertain to the parents/guardians.

NOTES:
♦ Financial assistance is only provided from time of application receipt and approval.

Applications cannot be processed until ALL required documents are received.
♦ Approval may take up to 30 days.
♦ Organization grant assistance is on a first-come, first served basis to the extent that funding is available.
♦ The Review Board sets the eligibility criteria, has final determination in all cases reserves the right to change its program in its entirety or with respect to any applicant at any time with or without notice.

Need is based on the current financial status and the
Dept. of Health & Human Services Poverty Guidelines:

% of Federal Guidelines   < = 250%      
Family Size of 1 $12,060 $30,015 Family Size of 5 $28,780 $71,950
Family Size of 2
$16,240 $40,600 Family Size of 6 $32,960 $82,400
Family Size of 3
$20,420 $51,050 Family Size of 7 $37,140 $92,850
Family Size of 4
$24,600 $61,500 Family Size of 8 $41,320 $103,300


Instructions:
Complete Financial Assistance Request Form and Patient Consent Form.
Medical Referral Form must be completed by your referring physician providing medical treatment (oncologist, surgeon, radiologist or social worker)

Types of expenses considered upon agreement with provider:
♦ Rent/Mortgage, Utilities, Food, Gas Cards. Vendor(s) to be paid directly by Hope Abounds.
♦ $500 cap per patient per year.

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Mail, fax or email completed application and supporting documents to:     
Hope Abounds, Inc.                                                                                        
1642 South 41st Street                                                                                        
Wilmington, NC  28403 

Fax:  910-778-1599

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