AMY B. SILVERMAN’S BRIDGING THE GAP FOUNDATION
Please Print and Complete this Application for Financial Assistance
PATIENT INFORMATION:
Name_______________________________________________________________________________________________________________________________
Social Secirity & Marital Status__________________________________________________________________________________________________________
Address__________________________________________________________________________________________________________________________
Primary & Alternate Phone____________________________________________________________________________________________________________
FINANCIAL INFORMATION:
Employer__________________________________________________________________________________________________________________________
Primary Source of Income______________________________________________________________________________________________________________
Secondary Source of Income____________________________________________________________________________________________________________
Number of Occupants, Their Relationship & Ages Who Are Living in Your Home__________________________________________________________________
________________________________________________________________________________________________________________________________
MEDICAL INFORMATION:
Date of cancer diagnosis or recurrence: _____________________________________________________________________________________________
Current treatments (please list all that apply) _________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
Do you have health insurance? □ Yes □ No
Insurance Provider and Phone_____________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PHYSICIAN’S NAME, PHYSICIAN’S PHONE, TREATMENT FACILITY
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
REFERRING HEALTHCARE PROFESSIONAL, TITLE, PHONE
_______________________________________________________________________________________
I have verified that this client is within three months of active cancer treatment, excluding long-term hormone therapy or experimental treatments.
Signature of referring healthcare professional & date
__________________________________________________________________________________________________________________________________________________________________________
Request Information
Amount of Request $ _____________________________________________________
To be used for
________________________________________________________________________________________________________________________________________________
Other resources tried and the results
_________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Original bills or coupons are required for payment. Bridging the Gap is only able to issue funds directly to vendors.
My signature below gives Bridging the Gap permission to contact my physician, referring healthcare professional, and vendors to verify information related to this application. I certify that my answers on this application are true and complete to the best of my knowledge. I understand that false or misleading information on my application may require the return of patient assistance funds.
Applicant signature
________________________________________________________________
Date ____________________________________________________________
Mail Application to:
Barbara Kughn
c/o Bridging The Gap Foundation
P.O. Box 1397
Richmond, VA 23218-1397
Questions: 804-405-1133
