Get Application For Financial Assistance - Eastern Band Of Cherokee

The Application For Financial Assistance provides crucial support to families in need. Filling out this form online is essential for accessing financial aid related to cancer treatment for children. Follow this comprehensive guide to ensure the application process is clear and manageable.

Follow the steps to successfully complete your application online.

1. Click ‘Get Form’ button to initiate the application process and open the form in your preferred online editor.
2. Begin by filling in the personal information section. This includes the patient's name, date of birth, and Social Security number. Make sure to provide accurate and complete information.
3. Indicate the patient's gender and their place of birth by entering the city and state. Fill in the patient's address and ensure all details are correct, including the marital status of the parents or guardians.
4. If the parents or guardians are not in the same household, both must submit an application. List the names of the parents or guardians and their contact information, including home and cell phone numbers.
5. Provide an emergency contact name, including their relationship to the patient and phone numbers to reach them.
6. In the section for requests, list your financial assistance requests in order of importance. Attach any relevant bills and vendor contact information to support your claims.
7. The medical information section must be completed by a healthcare professional. This includes the name of the hospital, physician, diagnosis, and the contact details of the medical personnel providing the relevant information.
8. Have your social worker submit a statement regarding the family's financial situation in the designated section.
9. Complete the consent to release information section, authorizing necessary entities to release relevant information to the Madison Hornbuckle Children’s Cancer Foundation.
10. Ensure all signatures are collected from the parents or guardians, affirming the information provided is correct, and the guidelines have been read and understood.
11. Once all sections are completed, review the application for accuracy. Save your changes, and then download, print, or share the form as required to submit it to the Principal Chief’s office.

Complete your Application For Financial Assistance online today to ensure your family's financial needs are met.