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Online Patient Application

April 13, 2010 By My Hope Chest Leave a Comment
Use the form below to fill out and submit our Patient Application Online

First Name
Last Name
Street Address
Apt#
City
State
Zip
Mailing Address / P.O. Box
Mailing Apt#
Mailing City
Mailing State
Mailing Zip
Home Number
Cell Number
Work Number
DOB - Enter as DD/MM/YYYY
Sex
Are you a US Citizen?
Email
Which of the following groups do you feel you belong to? (Response optional)
Other:
Marital Status
Emergency Contact:
Emergency Contact Phone:
State of Residency: How long have you been a full time resident in your state and city?
REFERRED FROM:
If referred from a hospital or breast center, enter facility name:
If you chose "Other" please name referral source:

RESPONSIBLE PARTY: (parent, or legal guardian information. If patient is 18 years or older, please print the patient’s information)
First Name
Last Name
Home Phone
Street Address
Apt#
City
State
Zip
Mailing Address or P.O. Box
Apt#
City
State
Zip
Social Security
Marital Status
DOB
Sex
Annual Income/ Source of Income
Employers Name
Employers Address
Employers Phone
If unemployed, for how long and why

ADDITIONAL INFORMATION
Do you have Medical Insurance?
Have you applied for insurance through the Affordable Care Act?
Reason Insurance Denied
Insurance Name
Have you applied for
What Program?
When Did You Apply?
Application Status
Mastectomy Type
When (Year)
Have you had radiation therapy?
What type of reconstruction are you seeking?
Have you seen a plastic surgeon yet? If so, who was it and what was the outcome?
Additional Services Needed
If your surgery could be paid for, would you be able to go out of state for the procedure?

Family Member Information
Name: (1)
Age (1)
Insurance? (1)
Name: (2)
Age (2)
Insurance? (2)
Name: (3)
Age (3)
Insurance? (3)
Name: (4)
Age (4)
Insurance? (4)

APPLICANT CRITERIA
Must be 69 years of age or under, free of medical complications that would preclude safe surgery (as determined by our participating surgeons and medical consultants), able to show demonstrable need* and a legal resident or citizen of the United States.
*Demonstrable need shall include consideration of the following criteria 1)Uninsured 2) Proof of non-eligibility for Medicaid 3) Income that does not support self- funding of care 4) Hardships or exceptional circumstances.

YOUR STORY:
Please provide a brief explanation of your journey through breast cancer and why you want to have reconstruction. Please limit to 500 words or less.
I authorize My Hope Chest to use my picture to help raise money.
(If Yes, please email picture to info@myhopechest.org and include your full name and email address)

Please enter the text in the image into the box below
Please enter the text in the image into the box below

By filling out and submitting this form, I attest that the information provided is accurate and true to the best of my knowledge. I understand that my application is NOT complete until I have all of my documents are received including: 1). Patient Application 2). Patient Agreement Form and all documents and letters therein. I understand that if I have falsified this application, I will be disqualified from the program.
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