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Application

Dear Applicant,

Thank you for your interest in the Alabama Oncology Foundation’s (AOF) Patient Financial Assistance Program. AOF is a 501(c)(3) charitable organization whose mission is to Help Oncology Patients Excel during their fight against cancer.

Enclosed is the AOF’s application for financial assistance. Please note that applications must be submitted to AOF by a referring professional (i.e., your doctor, a nurse, social worker, patient navigator, or other health care professional who is involved with your care). In addition, you must receive care in the following counties: Jefferson, Shelby and St. Clair. Please read the instructions carefully and fill out the application completely. Also, be certain to list all current expenses and complete income information. AOF uses this information to gain a complete understanding of your current financial situation. Be sure to attach copies of the bill(s) that you would like the foundation to consider for payment as well as proof of income documents. Please note that grants can be requested up to $1500. Referring professionals are asked to mail a completed application to the following address or email address:

Alabama Oncology Foundation
500 Office Park Drive, Suite 400
Birmingham, AL 35223

OR email catherine.frey@alabamaoncology.com

Thank you again for your interest in the Alabama Oncology Foundation. Should you have any questions about this application, please call (205)-443-5781 or via e-mail at catherine.frey@alabamaoncology.com

Sincerely, The Alabama Oncology Foundation Board

Please download the below form and attach to your submission. Thank you.

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Application

Name(Required)
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Check one of the following:(Required)
Ethnicity:(Required)
Address(Required)
Emergency Contact(Required)
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Are you currently receiving treatment?(Required)
Have you ever received financial assistance from The Alabama Oncology Foundation before?(Required)
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    All information I have provided is true and accurate. I understand that any financial assistance provided by the AOF is provided directly to my creditors, is limited, and is based on the immediate needs that negatively impact my health status. I understand this application will expire six months from date of the submission. Providing false information will result in denial of assistance.

    I authorize the AOF to contact my health care provider(s) listed above, and I authorize my health care provider(s) to release information to the AOF related to this application. If requested by my health care provider(s), I will complete an appropriate authorization to allow him/her to release information to the AOF pertaining to this application. All information provided to the AOF will remain confidential, except that the AOF may disclose information to my creditors and others as may be necessary to provide financial assistance.

    I fully understand that AOF’s funds to provide assistance may be limited and that I should coordinate a plan for long term financial support by contacting additional community resources.

    I understand that although the AOF may consider billing cycles and due dates when providing financial assistance, I remain fully responsible for timely payments of my debts, and I will indemnify and hold harmless the AOF for any expenses, losses, or liabilities arising from or related to my debts.

    MM slash DD slash YYYY
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