Wiskott-Aldrich Syndrome Family Assistance Application
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Name of applicant (not the patient) *
Address *
City, State, Zip *
Phone *
Email
DOB *
Social Security Number (it is secure) *
Are you a U.S. citizen?
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Please list all family members and their ages that reside in the patient's household. Please include their age and their relationship to the patient.
Please list the applicant's adjusted gross household income for the last two (2) years (please send us a copy of your Federal Income Tax Return for each of the last two (2) years)
Please list projected household income for the present calendar year:
Please list all assets other than your current residence, including the estimated value of each:
Please list total monthly living expenses, including rent or mortgage and utilities:
Please list total out-of-pocket medical expenses for the past 12 months:
Please list total out-of-pocket medical expenses projected for the next 12 months:
Name of applicant
Date of birth
MM
/
DD
/
YYYY
When was the diagnosis made?
Name and address of the facility currently providing primary treatment
How far is the facility from your home?
Who are the primary physicians? Please include the phone number and the name of the institution for each.
Please describe the current course of treatment:
What treatments has the patient undergone in the past 12 months?
Has the patient been forced to forego any treatments for financial reasons? Please explain
Please list and include documentation of total out-of-pocket medical expenses specific to the disease
Please list and include documentation of total un-reimbursed expenses related to treatment of the disease: Such additional expenses include, without limitation, (a) lodging and living expenses for the patient and his/her family en route to or at the treatment or care facility, (b) transportation costs (gas,airfare, parking and/or rental car if the family has no other alternative) en route to or at the treatment care facility, (c) child care (day care or after-school care) for any other minor siblings while the patient is undergoing treatment or care for WAS, and (d) additional or ongoing special needs and/or care of the patient, such as therapy.
What are the names of patient's primary health insurance and any secondary insurance providers. Has the patient been denied treatment or coverage by any insurer, and if so, for what procedures?Is the patient eligible for and has the patient applied for Medicaid and/or Medicare? If so, list the assistance being received.Please list any other assistance being received by family or patient.
Please describe any additional and/or extraordinary circumstances that would warrant assistancefrom the Foundation
The Wiskott-Aldrich Foundation will verify some of the information you've provided using medical records. Please select the reports that you give permission for medical professionals to release.
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