BREAST CANCER SOLUTIONS
Mailing Address: 3843 S. Bristol Street #152, Santa Ana, CA 92704-7426
phone: 866.960.9222 fax: 866.781.6068 website: www.breastcancersolutions.org
CLIENT APPLICATION BCS provides support for individuals living in Orange County, San Diego County, and Inland Empire who are going through breast cancer treatment, and whose income and/or expenses are significantly impacted by treatment for breast cancer. If you have completed surgery, chemotherapy, and/or radiation for primary breast cancer, are considered to have no evidence of disease (NED), and are now taking adjuvant Tamoxifen, Arimidex or similar hormonal treatment on a long-term basis, you are no longer considered to be in treatment for active breast cancer and are no longer eligible for assistance. If you stop treatment for any reason against your oncologist’s advice, you will no longer be eligible for assistance. BCS reserves the right to verify income, expenses, and treatment plan by requesting the following information.
Must provide proof of identification. Picture ID, CDL, California ID, passport, employment or school ID, or other acceptable identification and social security card, if available.
Must be a resident of Orange, San Diego, Riverside, or San Bernardino counties to be eligible for BCS support. Proof of location of residence by rent receipt, mortgage payment receipt or contract, or note from landlord; utility receipts, turn-off notice, late notice, eviction notice, fore-closure notice, 3 day notice to quit, etc.
Must provide verifiable income information for pre-treatment and during treatment. Earned and unearned income for spouse or other responsible persons living in the home must be included.
Must be in active treatment to receive BCS support. Current diagnosis, prognosis, surgery date, and treatment plan with date and signature of treating physician.
Must provide information about owned property including rental real estate, second homes, etc.
Must provide information about credit card payments, car payments, child care, child support, cable, furniture storage, health club, other legal obligations for spouse or other responsible persons living in the home.
Must demonstrate that available liquid resources are below $1,000 total limit; includes bank accounts, stocks, bonds and any other accessible items that can be readily converted. Inaccessible resources are exempt, such as 401k, IRAs, etc.
Complete pages 1-2 of the application. Page 3 contains an authorization for release of your medical information by your doctor. Fill this form out completely, and ask your doctor’s office (oncologist, surgeon - whomever you consider to be the head of your medical team) to make a copy. This form tells your doctor that you give him/her permission to provide information about you to BCS and should be kept in your chart. Enter your name and date of birth in Section I of page 4, and have your physician complete page 4, which will tell BCS about your breast cancer diagnosis and treatment plan. S/he should complete the form, attach pertinent pathology documentation, and may return it to you or mail or fax it directly to BCS. Please see the address, phone and fax numbers above.
Please note: Your application will not be processed until BCS has received all 4 pages, including the physician report (page 4). In order to complete the application process, you will be asked to interview with two BCS Client Support Volunteers.
**Please initial the bottom of every page of this application** Date of Application
(Age/Gender) & names of children: ( / )
Full disclosure is needed for your application to be considered BREAST CANCER SOLUTIONS
Mailing Address: 3843 S. Bristol Street #152, Santa Ana, CA 92704-7426
phone: 866.960.9222 fax: 866.781.6068 website: www.breastcancersolutions.org
How much was your income before breast cancer treatment?
How much were your expenses before treatment?
Why have your income and/or expenses changed during treatment?
Did someone help you with this application? No Yes
What medical insurance do you have? (Private, Medicare, MediCal, BCCTP, Medi-Medi, None)
CURRENT INCOME Monthly amount
1. Your wages/salary if you are currently working (after taxes)
2. Spouse/partner’s wages/salary (after taxes)
7. Disability (circle one through state through employer)
TOTAL OF ALL MONTHLY INCOME (Add lines 1 through 12 together): Please use the Other lines to indicate if you are receiving other Social Security benefits, pension or retirement benefits, Worker’s Compensation, child support/alimony, care of foster child, in-home care/in-home supportive services benefits, school grants/loans, general relief (Welfare), food stamps, CalWORKS (AFDC) or any other form of support. MONTHLY EXPENSES Monthly Amount
1. Mortgage or Rent Equity owned in Home $_______________
2. Gas __________ Electricity __________ Water __________ Trash _________ Cable __________ 2. $ (total)
5. Auto Loan __________ Auto Insurance __________ Gasoline ___________
6. Medications (related to breast cancer treatment only)
7. Medical co-payments and/or share of cost of breast cancer treatment
TOTAL OF ALL MONTHLY EXPENSES (Add lines 1 through 10 together):
Please check this box if applicant would like to be referred to other agencies for possible assistance. Referrals may result in
sharing applicant’s information between BCS and other agencies.
By signing below, I agree that the above information is true and correct.
Full disclosure is needed for your application to be considered BREAST CANCER SOLUTIONS
Mailing Address: 3843 S. Bristol Street #152, Santa Ana, CA 92704-7426
phone: 866.960.9222 fax: 866.781.6068 website: www.breastcancersolutions.org
APPLICANT AUTHORIZATION FOR RELEASE OF INFORMATION
Doctor or Medical Group From Whom Information is Requested (e.g., your oncologist)
hereby authorize you to release to Breast Cancer Solutions non-profit organization (33-0765783) specific information
requested by them which I cannot provide concerning:
This information is needed to determine my eligibility for assistance from Breast Cancer Solutions (BCS). I have read
this form and have agreed to its request prior to my signing.
Note: Provide this form to the physician or other agency from whom you are requesting the release of information to Breast Cancer Solutions. Full disclosure is needed for your application to be considered BREAST CANCER SOLUTIONS
Mailing Address: 3843 S. Bristol Street #152, Santa Ana, CA 92704-7426
phone: 866.960.9222 fax: 866.781.6068 website: www.breastcancersolutions.org
PHYSICIAN’S REPORT
The individual listed below has requested assistance from Breast Cancer Solutions (BCS) and has stated that s/he is unable to work or is unable to work at pre-treatment level. A signed release for the requested information is attached.
Please complete this form and return it by: ____________ (date) Attn: Director of Client Services Phone: 866.960.9222 Breast Cancer Solutions 3843 S. Bristol Street #152 Fax: 866.781.6068 Santa Ana, CA 92704-7426
SECTION I SECTION II – TO BE COMPLETED BY YOUR PHYSICIAN
Pertinent pathology results (please attach copy of pathology report):
Indicate client’s prognosis: Good Fair Guarded Other:
What level of employment activity is suitable for patient? Part-time ____ hours per week Full-time
Projected date patient can return to work at pre-treatment level:
Other Planned Treatments (chemo, radiation, etc.)
Full disclosure is needed for your application to be considered
Ramah Nyack - D'var Torah - Tzav- Purim Friday, March 21 Aviva Buechler, currently a freshman at Barnard College, has worked as a counselor in Nitzanim for the past two summers. In January Aviva was a Nyack representative at the Weinstein Leadership conference in Ojai, California. Aviva will always greet you with a warm smile.especially if you are a celebrity she spots on the street! Aviva can