2020 Financial Assistance Application

2020 Application for Financial Assistance

The BTB Foundation is a non-profit 501(c)(3) tax exempt organization that provides financial assistance to cancer patients and their families.

The BTB Foundation will make a selection of cancer patients from the Chicago area that display financial need and that meet the BTB Foundation selection requirements to receive a financial award based on the applications submitted on time (before cutoff date of Tuesday 12/31/2019) and with all required information.

The number of financial grants that The BTB Foundation can award is based on the amount of annual income raised by The BTB Foundation. General support and involvement of all participants and their families and friends is critical in the success of the annual BTB Foundation's outing.

The information entered on this application will be reviewed by The BTB Foundation and the Beat Tom and Bill Charity Golf Outing Committee. All information is strictly confidential and is for The BTB Foundation and the Beat Tom and Bill Charity Golf Outing Committee use only.

Please complete all required sections and provide as much detail whenever possible. We also ask that you provide the supporting reference letters and your statement of diagnosis before the December 31st deadline so that we can review all relevant information
as we evaluate your application (incomplete applications/applications without the requested reference letters and statement of diagnosis will not be reviewed until all requested documents are provided.)

If you have any questions or if you need any assistance while completing this application, please contact Bill Latourette at 847.830.1907 or email us at: [email protected].

Applicant Information

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone number (home) *

Phone number (cell) *

Best means of communication *

home phone cell phone/text email

Date of birth *

Applicants gender *

Are you currently employed? *

If 'yes' to above, name of employer *

Do you own/rent? *

Own Rent Not applicable

What is your monthly rent/mortgage payment? *

Guardian Information (if applicant is a minor)

Name *

First

Last

Relationship to applicant *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone number (home) *

Phone number (cell) *

Best means of communication *

home phone cell phone/text email

Date of birth *

Are you currently employed? *

If 'yes' to above, name of employer *

Comment *

Email *

Do you own or rent? *

Own Rent

What is your monthly rent/mortgage payment? *

What is a Champion?

A Champion is The BTB Foundation's main point of contact and will be the liaison between The BTB Foundation and the applicant. The Champion can be a close friend, family member (other than the husband/wife or mother/father of the applicant) or any person that is close to the applicant. The success of The BTB Foundation's outing and our ability to provide assistance to the applicant is dependent upon the applicant selecting a Champion that is dedicated to assisting the The BTB Foundation during the planning stages or our event.

The BTB Foundation will reply on the Champion to:

Provide pictures and information about the applicant
Answer questions The BTB Foundation may have about the applicant
Keep The BTB Foundation informed about the applicants medical condition
Keep the applicant and his/her family and friends informed about The BTB Foundation's 2020 Golf Outing and Celebration Dinner
Actively promote The BTB Foundation and the 2020 BTB Golf Outing and Celebration Dinner to the applicants family and friends
Attend all Champion meetings (4-5 meetings to discuss/plan the 2020 outing - meeting dates and times to be provided)

Champion name *

First

Last

Relationship to applicant *

Phone number (home) *

Phone number (cell) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Best means of communication *

home phone cell phone/text email

Email *

Signature of Champion (I have read the above responsibilities and agree to comply to the best of my abilities) *

Medical Information

You understand that Congress passed a law entitled the Health Insurance Portability and Accountability Act (HIPAA) that limits use, disclosure or release of my individually identifiable health information, as HIPAA and the supporting Regulations define that phrase. I am signing this authorization because it is crucial that my health care providers release, or disclose my protected medical informattion to BTB Foundation and its directors and members, for the sole purpose of obtaining a statement of diagnosis from my treating physician for the purposes of this application for financial assistance.

With regard to information disclosed under this authorization, you waive any right of privacy that you may have under the aurhority of the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA), any amendment or successor to that Act, or any similar state or federal act, rule, or regulation. In addition, you release any covered entity that acts in reliance on this authorization from any liability that may accrue from the use or disclosure of your individually identifiable health information in reliance upon this authorization and for any actions taken by The BTB Foundation.

Primary cancer type *

Date of diagnosis *

Cancer stage (if applicable) *

Is this a new cancer diagnosis? *

yes no

Please explain *

Are you currently receiving cancer treatment? *

yes no

Date of last treatment *

Please describe the treatments you have received in the past 12 months *

Please describe any treatments/costs not covered by health insurance *

Does the applicant have health insurance? *

yes, the applicant has health insurance no, the applicant does not have health insurance

If the applicant is covered by health insurance, does the insurance cover prescription drugs? *

yes, the applicant's insurance covers prescription drugs no, the applicants insurance does not cover prescription drugs n/a, the applicant does not have insurance

Statement of Diagnosis

A statement of diagnosis provided by your physician is required before The BTB Foundation can complete the review of your application. Please submit the Statement of Diagnosis to The BTB Foundation by:

Email to [email protected]
Fax # 224-267-0788
Mail to: BTB Foundation, 820 W. Dresser Drive, Mt. Prospect IL 60056

Note: Under the Health Insurance Portability and Accountability Act (HIPAA) you are required to provide an authorization and release for The BTB Foundation to obtain the statement of diagnosis. Your completing and submitting this application provides The BTB Foundation with the HIPAA Authorization and Release requirements.

Financial Information

Is the applicant currently employed? *

yes no

Combined household gross income of family applying for assistance *

If the applicant is a minor, are the applicant's guardian's currently employed? *

yes, guardian's are employed one guardian does not work so that they can care for the applicant both guardian's do not work so that they can care for the applicant

Please describe the applicant's household sources of income (examples include wages, family assistance, social security, disability, public aid, pension and unemployment) *

Please describe how you intend to use the funds if you are selected as a recipient of the 2020 BTB Foundation (please provide as much information/detail as possible) *

Additional Information

Please provide any additional information that you would like The BTB Foundation to know/consider while reviewing your application *

Sharing names and email addresses of family and
friends with The BTB Foundation

Your family and friends participation in The BTB outings are critical to our success. The BTB Foundation will invite your friends and family to BTB fundraising events. Any names and/or email addresses you provide will only be used by The BTB Foundation and will not be shared with any other party *

Yes, I am willing to share names and addresses of family and friends with The BTB Foundation No, I am not willing to share names and email addresses with The BTB Foundation

We'd love to know how you heard of The BTB Foundation! Please tell us in detail who or what (newspaper article, radio, etc.) introduced you to our organization (please be specific). *

Submitting a Completed Application

In order for The BTB Foundation to review your application, the following must be completed and submitted before the Tuesday 12/31/2019 deadline. Failure to provide all the required information below may delay or forfeit any consideration from the foundation:

(1) Electronically sign this application
(2) Compete all required fields and click on the 'submit' button (below)
(3) Submit a Statement of Diagnosis from your doctor
(4) Provide two to three reference letters from family and/or friends describing why the BTB Foundation should consider your request.

The Statement of Diagnosis and the reference letters can be sent to The BTB Foundation via:

Email to: [email protected]
Fax # 224-267-0788
Mail to: BTB Foundation, 820 Dresser Drive, Mt. Prospect, IL 60056

Background Check

In order to protect you and The BTB Foundation from fraud, we require that a criminal background investigation be administered. This does not include a credit report or a credit history. The criminal background investigation is at no cost to you and is the responsibility of The BTB Foundation. All information obtained, if any, during the criminal background investigation will be provided to you. BTB Foundation will hold the information confidential and will not release the information to any third parties. We are required to obtain authorization from you to complete this criminal background investigation.

By electronically signing this application below, you are hereby consenting/authorizing the BTB Foundation to complete a background check of the applicant / applicant's guardian.

Electronic Signature

Applicant Name (guardian name if applicant is a minor) *

I confirm that I am the applicant/applicant's legal guardian and I confirm that by entering my name in the applicant name field I have electronically signed this application *

yes, I confirm my electronic signature no, I am not the applicant/applicant's legal guardian and I have not electronically signed this application

Submit

Application for FinancialAssistance

2020 Application for Financial Assistance

Applicant Information

Guardian Information (if applicant is a minor)

What is a Champion?

﻿Medical Information﻿

Statement of Diagnosis

Financial Information

Additional Information

Sharing names and email addresses of family andfriends with The BTB Foundation

Submitting a Completed Application

Background Check

Electronic Signature

Application for
Financial
Assistance

Medical Information

Sharing names and email addresses of family and
friends with The BTB Foundation