Kim's Hope · Application For Financial Assistance

PATIENT Information

Please provide details on the patient for which aid is being applied for.

Name

*

First Name

Last Name

Birthdate

*

(mm/dd/yyyy)

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Phone

*

Email

*

Verify Email

*

Organization/Employer

Please provide past or current Employer

Positition/Title

Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Currently Employed?

*

Yes

No

How long at this company?

Names and ages of children

Name of spouse/significant other

Is spouse/significant other currently employed?

Yes

No

Spouse/Significant Other Employer

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Is spouse/significant other the primary caregiver?

Yes

No

If spouse/significant other is not the primary caregiver, please provide name of who is and their relationship to patient

Is the patient able to walk on their own?

YES

NO

Is the patient able to drive?

YES

NO

How did you hear about Kim's Hope?

*

Healthcare Team/Doctor

Website/Internet Search

Social Media

Referred by another patient

Event

Other (please specify below)

Other:

Name of person completing this form:

Relationship to patient

If this form is being submitted by someone other than the patient, I certify that I am authorized to act on behalf of the patient and provide/discuss their medical condition. If you are someone other than the patient, spouse, parent, or helath care provider a notarized Power of Attorney may be required for consideration of this application and discussion of a potential grant award.

As a secondary means of getting to know our applicants better, and in an effort to make the best decsions regarding where we distribute funds, our application process will include a virtual interview with the patient, caregiver, and/or other family members submitting this application. Doing so affords us the opportuinity to get to know you better, allows you to get to know us better, and provides the opportunity to connect in a manner beyond what is possible in a written application.

I agree to these conditions of the application process

*

First Name

Last Name

I have the ability to attend a virtual interview

YES

NO

Email to send invitation

please provide the best email address to schedule this video interview

Verify Email

Best day(s) of week and time(s) to conduct virtual interview

Video Interviews typically last 20-30 minutes

Insurance & Finances

Is the patient covered by medical insurance?

*

YES

NO

Type of Insurance

Private (provide detail below)

Medicaid

Medicare

VA

Other (provide detail below)

If "Private", company name

Name of insurance company

If "Other", please specify

Annual deductible (if applicable)

Annual "out of pocket maximum"

Is there a separate annual deductible for prescription drugs?

YES

NO

If "YES", How much?

Is there a separate "out of pocket max" for prescription drugs?

YES

NO

If "YES", How much?

Income

What was your total HOUSEHOLD income for:

2020:

2021:

2022:

What is your monthly income from the following sources:

Salary/Hourly Wages

Unemployment

Social Security

SSD Disability

Short-Term Disability

Long-Term Disability

Public Assistance

Family/Friends

Other: Please Specify

Have you ever applied to other charitable organizations or foundations for financial aid?

YES

NO

How much aid are you applying to receive?

What would be the primary use(s) of the aid received?

Have you ever generated financial aid aid through "GoFundMe" or another public funding source?

YES

NO

If "YES" please specify organization, date, and amount of grant

If "YES" please specify date and amount raised

Expenses:

Please list your approximate MONTHLY expenses for:

Rent/Mortgage

Utilities (Gas, Electric, water, etc.)

Car Payment

Phone, Cable & Internet

Approximate Monthly Fuel

Insurance (auto, home, life, disability, etc.)

Credit Card Payment

Other Loans (please specify)

Kim's Hope reserves the right to request further financial information, includiong prior W2 of 1040 tax forms to ensure the aid we distribute is received by those with the most need. By entering my name below, I certify that the financial information conatined on this application is true and accurate, and agree to provide addtional information as requested by Kim's Hope.

*

First Name

Last Name

Medical Information

Date of initial GBM diagnosis:

*

(mm/dd/yyyy)

Date of recurrence (if applicable):

(mm/dd/yyyy)

Pathology Report

*

Please provide documentation showing physician-confirmed diagnosis of glioblastoma

Name of primary treatment facility

*

City/State of Primary Treatment Facility

Please provide dates and types of surgical intervention(s)

biopsy, resection, ablation, etc.

Neurosurgeon's Name

*

Hospital/Clinic Name

Oncologist/Neuro-Oncologist's Name

*

Hospital/Clinic Name

Is the patient currently receiving active treatment?

*

YES

NO

If "YES" please provide details on type and frequency

Is the patient currently receiving hospice care?

*

YES

NO

Name of Hospice Organization/Provider

Please provide details and timeline of the patient's journey from initial diagnosis to present time (include all treatments completed and successes/failures of those treatments as well as any alternate or addtional treatment plans under consideration)

*

Additional Information

We would love to get to know the patient and their care team, and the personal side of your stories outside of the GBM diagnosis. Please tell us about your career(s), your personal interests, your family, your faith, and anything else you can share that would give us a better picture of your life both before and after diagnosis. We love to receive pictures as a supplement to your application which can be attached below or emailed to todd.veenhuis@kimshope.org

*

Attach your pictures here

Kim's Hope requests the ability to highlight the stories of our recipients on our website, social media stories, newsletter, and other promotional materials. Only those that are awarded aid will be included. Please indicate your willingness to have your strory and pictures used on future Kim's Hope materials to help advance our mission of providing aid to maore families in need and to help build awareness of glioblastoma and the families fighting against it.

*

My information can be used by Kim's Hope to advance their mission

Please do not use my information

I certify that all information contained within this application is accurate to the best of my knowledge and that I will provide addtional information requested by Kim's Hope if necesary to complete the application process.

Name

*

First Name

Last Name

Email

*

Verify Email

*

Phone

*

Application for Financial Aid

PATIENT Information

Insurance & Finances

Medical Information

Additional Information