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Application For Assistance

PATIENT’S INFORMATION

Home Address

MEDICAL INFORMATION

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PERSONAL AND FAMILY INFORMATION

Net Worth

Mission4Maureen is a tax-exempt, non-profit foundation. As such, Mission4Maureen may engage only in those activities, which are charitable in nature. Mission4Maureen may provide grants to individuals to “provide financial relief ” or to aid individuals in “distress.” The information, which you provide, on this Net Worth Statement will be used exclusively by the foundation to determine your eligibility for financial assistance. The foundation will not disseminate or release the provided information to outside sources without first obtaining your prior express consent. The following financial information is being submitted by the applicant in consideration of possible financial assistance.

I. Assets

A. Liquid Assets                                                    Current Value in ($)
B. Fixed Assets                                                       Current Value in ($)
II. Liabilities:                                                           Total Current Balance in ($)
Liabilities:                                                               Monthly Payment in ($)

Medical Release

Please read and e-sign below. Make sure to have this medical release e-signed and dated by a witness (an adult 18 or older other than yourself).

I understand and grant my permission to all my doctors, social workers, clinics and hospitals to release all healthcare and billing information relating to my treatment and care for brain cancer and other related health problems to the Mission4Maureen Foundation. I also grant my permission to discuss the above information with any designated representative of Mission4Maureen by phone.

Mission4Maureen agrees that all medical information will remain confidential and any reports written about the program will not use any participants’ names without their express permission. I specifically authorize the release of all my healthcare and billing information in your organization’s possession. The purpose of my request is to assist Mission4 Maureen in determining my eligibility for financial assistance. This Release and Authorization shall expire twelve (12) months from its execution if not revoked prior thereto. Mission4Maureen will not disseminate or release these medical records to any outside source without first obtaining prior express consent. I understand and agree that fulfillment of assistance may result in publicity whether or not Mission4Maureen actively takes steps to publicize its service. I understand and recognize that the granting of any service and the participation of any person in the assistance is contingent upon approval by the Mission4 Maureen foundation. I also understand that there is a limit to the number of services that I will receive, depending on the type and cost of service being requested and offered. I understand and agree that no promises or assurances whatsoever have been made to me by any representatives of Mission4Maureen regarding the assistance I am requesting.

PUBLICITY NOTICE-RELEASE

Mission4Maureen may hold events and fundraisers throughout the year to raise money to fund the primary objective of the foundation: to help families endure the staggering cost of brain cancer treatment. People continue to support us because they want to see their money find its way to the people who need it the most. We need your help to put a face and a name to that reality. To this end we will use your photo, your name, and your submitted story. If your application is approved, Mission4Maureen may also use a brief description of how the assistance that you received has helped you. This will facilitate communication with our donors and help in attracting more contributors. Please acknowledge this notice-release by e-signing below:I hereby acknowledge that Mission4Maureen may use my name, photo, background and story in PR and marketing materials which will include, but not be limited to, its newsletters, website, mailings and general information brochures.
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Please note: If approved or denied or if we need to ask for a clarification or more information, you will be contacted through the email address that you have provided in this application.