Patient Consent Form

Hope abounds
1642 S. 41st Street
Wilmington, NC 28403
910-799-7178

 RELEASE OF PERSONAL INFORMATION AND AUTHORIZATION

Patient Consent Form

  • I have read the Hope Abounds Eligibility Criteria and I declare that the information furnished on this financial application is true and accurate to the best of my knowledge. hereby give permission to Hope Abounds to request a Medical Referral from the surgeon or oncologist and also to contact state and local community agencies in order to identify financial resources that may be available to assist me. I hereby give my permission that this application and all the information provided be sent to Hope Abounds. I understand that this application and all information is confidential and will be reviewed on a case-by-case basis, with final determination made by the Review Board of Hope Abounds. I understand that there is a limit to the number of services I may receive within a 12 month period and that there are no promises or guarantees that financial assistance will be provided. I understand that any elective procedures (cosmetic surgery/breast implants) are not eligible for financial assistance. If any information that I have provided proves to be untrue, I understand that Hope Abounds will re-evaluate my financial assistance request.

Hope Abounds, Inc.
A 501(c)(3) charitable organization.
Charity Number 27-1858542

Women of Hope and A Kids Hope are both programs of Hope Abounds, Inc. that has dedicated itself to enhancing the life of a female, child or teen cancer patient and their families. Hope Abounds does this by providing support services, supporting educational opportunities, patient advocacy and financial assistance. These services are designed to help with the emotional, physical, and spiritual needs of all that have been touched by cancer. By providing free of charge opportunities one can join with others to share their experiences, strengths and most importantly, their hope!

Due to the tremendous growth of Women of Hope over the past six years, we have developed a new program to provide for children and teens who have received a cancer diagnosis called A Kids Hope.  Both of these programs, Women of Hope and A Kids Hope, are now operating under our corporate name of Hope Abounds, Inc.  This latest expansion of services happened in the last quarter of 2015 and will be fully implemented through the year of 2016.

By helping to meet some of the basic needs of those who are battling a cancer diagnosis, Hope Abounds, Inc. is instrumental in allowing the patient and family to concentrate on being their own best advocate during their treatment.  Hope Abounds provides educational and support programs, helping with patient advocacy and offering financial assistance.  We offer hope that you are not alone in your journey!

We are enthusiastic to share that we are partnered with the Pediatric Staff at UNC Chapel Hill this year as we launch A Kids Hope programs. The scope of reach and influence for Hope Abounds, Inc. continues to grow as we partner with major hospital systems through the region to bring education, hope, awareness and hopeful prevention of cancer through education for future generations.

Life’s Amazing, Pass It On.....