Cancer Financial Assistance

Apply for cancer benefits and get the cancer financial assistance you need to our non-profit charitable cancer foundation in greater Philadelphia. Are you in need of cancer financial assistance and cancer financial aid for your medical bills? Our financial counselors at Rachel’s Helping Hands can assist you with the application process to our Rachel’s Helping Hands Grant Program. We serve Bucks County, Montgomery County, Chester County, Delaware County, Philadelphia, and all surrounding counties in PA & NJ.

Cancer Benefits – Apply Today

To apply for cancer financial assistance and cancer financial aid, you must make available certain detailed financial information concerning income and assets. Please have the following patient information when you call or apply:

  • Name
  • Insurance Info
  • DOB
  • Tax Returns, Last 2 Years
  • Phone
  • Address
  • Household Income

Please call our non-profit charitable foundation & our financial assistance office at (215) 322-2065 and ask for Murray Fox, or apply online here and filling out the financial application form below medication application, in addition to our HIPAA policy.

Rachel’s Helping Hands Cancer Foundation
1200 Bustleton Pike
Suite 3
Feasterville, PA 19053
Email: info@rachelshelpinghands.org

Apply today for cancer financial aid to our Non-Profit Charitable Foundation.  We are constantly servicing:

    • Bucks County
    • Montgomery County
    • Lehigh Valley
    • Chester County
    • Delaware County
    • Delaware County
    • Philadelphia
    • All surrounding areas of PA
  • All surrounding areas of New Jersey

We have been designated as a 501(c)3 by the IRS

RACHEL'S HELPING HANDS CANCER FOUNDATION


NOTICE OF PRIVACY PRACTICE


SUMMARY

WHAT IS THE NOTICE FOR? This notice of Privacy Practices (Notice) describes how Rachel's Helping Hands Cancer Foundation (We or US) may use and disclose your medical information that we maintain and how you can get access to this information.

WHO ARE WE? RACHEL'S HELPING HANDS CANCER FOUNDATION is a non• profit organization which provides monies for cancer patients who cannot afford their deductibles.

WHY DO YOU NEED THIS NOTICE? The Health Insurance Portability and Accountability Act of 1996. as amended by the Health Information Technology for Economic and Clinical Health Act, places certain obligations upon us with regard to how we may use and disclose your personal health information (PHI). Your PHI includes medical information about you such as your medical records and the care and services that you have received. We are committed to maintaining the privacy of your PHI. When we need to use or disclose it, we will comply with the full terms of this Notice. Anytime we are permitted to or required to share your PHI with others, we only provide the minimum amount of data necessary to respond to the need or request unless otherwise permitted by law.

WHEN CAN WE USE/DISCLOSE YOUR PHI? There are certain uses and disclosures of your PHI that we may undertake without your written or other authorization. These uses and disclosures may be for purposes such as to provide you with treatment, obtain payment for services we have provided, and other health care operations (such as administration, quality improvement, cost studies and other activities designed to improve the service we provide to all our patients). Some other examples include: PHI made known to your relatives, close friends, or caregivers, public health activities and officials, reporting of abuse or neglect as may be required by law, health oversight activities, judicial and administrative proceedings, law enforcement officials, workers' compensation, and other individuals and activities as set forth in this Notice. Individuals who may have access to your information without your written or other authorization may include doctors, nurses, health care students, and other hospital staff.

WE MUST OBTAIN YOUR WRITTEN AUTHORIZATION FOR ANY USE OR DISCLOSURE NOT SET FORTH IN THIS NOTICE. You may revoke this authorization at any time. In addition to obtaining your written authorization for uses or disclosures not described in this Notice, we generally will also need to seek your written authorization or approval prior to disclosing the following information:

• HIVIAIDS related information
• Sexually transmitted disease information
•Psychotherapy notes
•Mental health information
•Drug and alcohol information
•Genetic information
•Any information where you, if a minor, sought emancipated treatment (e.g., care related to your pregnancy or child, sexually transmitted diseases, etc.)

We will also seek your written authorization for any "marketing" activities we may conduct or where we would receive money for providing a third party with your PHI.

WHAT RIGHTS DO YOU HAVE FOR YOUR PHI? You have the right to ask us to limit certain uses and disclosures of your PHI. We will consider ALL request but may not be required to agree to your requested limitations. You also have the right to inspect and receive copies of your PHI, the right to request a change or amendment be made to your PHI, the right to an accounting (a list) of certain disclosures of your PHI, and the right to revoke any authorization you may have made to the extent we have not yet relied upon it. You also have the right to receive a paper copy of this Notice at any time.

CAN WE CHANGE THIS NOTICE? We may change this Notice at any time. The revised Notice will apply to all PHI that we maintain. However, ifwe do change this Notice, we will only make changes to the extent permitted by law. We will also make the revised notice available to you by posting it in a place where all individuals seeking services from us will be able to read the Notice. You may obtain the new Notice in hard copy as well from our Privacy office.

ADDITIONAL INFORMATION/COMPLAINTS. You may contact our Privacy Office if you wish any additional information or have questions concerning this Notice or your PHI. If you
feel that your privacy rights have been violated, you may also contact our Privacy Office and file a written complaint with the Office of Civil Rights of the U.S. Department of Health and Human Services. We will NOT retaliate against you if you file a complaint with us or the Office of Civil Rights.

THE ABOVE IS ONLY A SUMMARY OF THE RIGHTS AND OBLIGATIONS WITHIN THIS NOTICE. PLEASE READ CAREFULLY THE ENTIRE NOTICE THAT FOLLOWS. WE WELCOME ANY QUESTIONS YOU MAY HAVE.

RACHEL'S HELPING HANDS CANCER FOUNDATION

CONFIDENTIAL COMMUNICATION LIST

MM-DD-YYYY

TERMS OF ACCEPTANCE and SIGNATURE

I, the [applicant] for this application of benefits, warrant the truthfulness of the information provided in this application.

Please type your First and Last Name

STEP 1- PERSONAL INFORMATION

MM-DD-YYYY
optional

You must be a US Citizen or legal resident to be eligible for assistance.

YOU MUST BE IN ACTIVE CHEMOTHERAPY OR IN A RADIATION TREATMENT PROGRAM TO RECEIVE ASSISTANCE. PLEASE CALL THE FOUNDATION AT 215-322-2065 IF YOU HAVE ANY QUESTIONS.

STEP 2- PRESCRIBING INFORMATION

STEP 3- INSURANCE INFORMATION

Insurance Company Name
Insurance Address
Insurance City, State
Insurance State
Insurance Zip
Insurance Phone
Insurance Fax

STEP 4- INCOME INFORMATION

Income Sources - YEARLY Gross Income

Salary (before taxes)

Unemployment Income

Medicare Wages or Social Security Disability

Retirement Income

Non Taxable Income

Interest/Dividends/Rental Income

Alimony/Child Support

Net Business or Other Income

TOTAL

STEP 5- ASSET INFORMATION

Asset Sources

Cash in Banks

Marketable Securities

Real Estate Owned
(excluding Primary Residence)

Other Assets

TOTAL ASSETS

STEP 6- PROOF OF CO-PAYS OR OUT OF POCKET MEDICAL EXPENSES

You must provide proof of co-pay or medicala expenses to be considered for reimbursement.


I hereby acknowledge that the information given herein is true and correct. I authorize The Rachel Paster Helping Hands Foundation, Inc. to verify any information contained in this document for the sole purpose of assessing financial need. Application will not be processed if this information is not provided.

Please type your First and Last Name
Please type your First and Last Name
Format: PNG, JPG, PDF

Please type your First and Last Name

STEP 7- THE RACHEL PASTER HELPING HANDS CANCER FOUNDATION, INC

Consent Information

I give The Rachel Paster Helping Hands Cancer Foundation, Inc. permission to:
1. Check my information to make sure it is true and complete.
2. Share my information with the people helping with the foundation.
3 Contact me by mail or phone about the Foundation and about other programs of service that might interest me.

I promise that:
1. All the information in this application, including all copies of documents providing my income, is true and complete.
2.I am authorized to sign this application.
3 I will contact the Foundation if any of the information about my prescription drug coverage, insurance status, pharmacy/infusion provider changes and/or my employment or salary changes
4.I do not receive any other financial assistance for the expenses that I have asked the Foundation to cover. This includes Medicaid, state drug assistance programs, and medical flexible spending accounts.
5 I am not receiving other financial assistance from other co-payment assistance programs for the same medical expenses and/or co-pays.

I understand that the Foundation will only use my information to:
1. Decide if I qualify to participate in the Foundation's medical or co-pay assistance program.
2. Administer or improve the Foundation.

I understand that I can call 215-322-2065 at anytime to:
1. Withdraw from the Foundation.
2. Cancel my permission to use my information and withdraw from the program.

I understand that:

1. The Foundation can ask for more information from me at any time.
2. The Foundation permission to contact the person named below with follow-up questions about my application (this applies only if someone completed this
application for you).

If a family member or someone helped you with this application and you want them to answer the questions for you, please provide their name and phone number.

Signature of Applicant

Please type your First and Last Name