THE NEW MEXICO CANCER CENTER FOUNDATION Providing Hope for Cancer Patients Our Mission: The New Mexico Cancer Center Foundation (NMCCF) is dedicated to supporting our patients’ non-medical needs during their battle against cancer. Through the combined efforts of the New Mexico Cancer Center and the Foundation, we recognize that medical treatments are only a part of the challenge for patients battling cancer. We understand the importance of combining state-of-the-art medical care, compassion and support for the patient and their family. With the generosity of many wonderful community businesses and individuals, the NMCCF is able to provide patients and their families a comprehensive support system. This includes non-medical financial support, free counseling and educational programs, pro-bono legal and financial assistance and free Continuing Medical Education programs for New Mexico’s physicians. Education is critical in improving cancer care, early diagnosis and better outcomes for all New Mexicans.
About us: We establish assistance and educational programs to meet the financial, emotional and psychological needs of patients. We serve cancer patients who receive care at the New Mexico Cancer Centers in Albuquerque, Gallup, Ruidoso and Silver City. Guided by a board of directors, The NMCC Foundation is situated within the New Mexico Cancer Center facility. Our goal is not only to provide support, but to remove barriers for cancer treatment while reducing our patient’s stress. Why? Because we want to facilitate the healing process and improve the quality of life of those going through cancer. Our fundraising efforts include the Duke City Marathon, golf tournaments, Sandia Volleyball Tournament and the New Mexico Cancer Center Fine Art Gallery, “Gallery with a Cause.” Through the support of the New Mexico Cancer Center, nearly all administrative costs for the Foundation are underwritten so almost 100% of donations can be used for patient grant and education programs.
New Mexico Cancer Center Foundation Information
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If you Need Assistance-How to apply for help from the NMCCF: The grant application procedure and application form may be found online at: www. nmcancercenterfoundation.org You may also call the New Mexico Cancer Center Foundation, 505.828.3789 to receive more information or to have an application sent to you. Applications are accepted year-round. The Foundation Grant Committee meets monthly to review applications. To be considered for a grant, applicants must be undergoing active treatment at one of the New Mexico Cancer Center locations. The maximum amount for most grants is $1000 over a one-year period. Through the Susan G. Komen for the Cure, Central New Mexico Affiliate, breast cancer patients in Bernalillo, Valencia, Santa Fe and Sandoval County may receive up to $1500. Applications must be signed and dated by the applicant All pertinent information about income sources and expenses must be completed. Please include a photocopy of relevant records. Documentation to verify application information will expedite the application process. Applications cannot be reviewed by the committee until they are complete. Please be sure to include the mailing and payment contact information for requests. (e.g., if requesting payment for your rent, include name of landlord or management company, the full mailing address, phone contact and copy of statement for rent.) All payments are made directly to 3rd party vendors to cover essential household expenses for patients who are under active treatment at the New Mexico Cancer Center. An example of what might be covered would be: utilities, rent/mortgage payment, transportation expenses, grocery, gas or lodging. Cable TV or internet would not be considered an essential household expense.
Ways you can help and get involved: We gratefully accept donations of time and treasure. When you volunteer with the New Mexico Cancer Center, your time is important to our cancer patients and to us. Volunteers assist with greeting, providing patient support at the centers; help with administrative tasks, with fundraising activities, and with coordination of special programs for our patients. Community leadership also forms the core of the New Mexico Cancer Center Foundation’s Board of Directors and many of our fundraisers. New Mexico Cancer Center Foundation Information
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The generosity of community members is what makes it possible for the New Mexico Cancer Center Foundation to help so many cancer patients throughout New Mexico. Without the generous support of our community, our Patient Assistance Program could not exist. Many people think they are not wealthy enough to make a gift that can make a real difference. As a small foundation with little overhead, every gift, large and small, makes a great difference in providing hope to cancer patients throughout New Mexico. There are many different ways you can help cancer patients:
Volunteer your time at the New Mexico Cancer Center Make an annual fund gift—it could be in honor or memory of someone dear to you Purchase art from the Gallery with a Cause- 30% of the proceeds are tax-deductible and go directly to support patient grants Donate assets you no longer need- stocks, bonds, insurance policies, automobiles, boats, art or developed or undeveloped property. The NMCCF has Board Committees dedicated to assisting with these types of transactions. Include the New Mexico Cancer Center in your estate planning or will Designate your United Way Giving to the New Mexico Cancer Center Foundation Hold a fundraiser with your family and friends
There are many ways people can get involved and make a great difference to cancer patients here. Feel free to contact the New Mexico Cancer Center Foundation with any questions or to share thoughts you may have about the Foundation. We’re here to help and we look forward to hearing from you!
Important Contact Numbers:
New Mexico Cancer Center Foundation Phone: 505.828.3789 Fax: 505.857.8480
New Mexico Cancer Center Foundation Information
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NEW MEXICO CANCER CENTER FOUNDATION 4901 Lang Ave NE, Albuquerque, NM 87109 Phone: 505.828.3789 Fax: 505.857.8480 Adult Patient Assistance Application
Revised 5/7/2012
ADULT PATIENT GRANT APPLICATION (I)
Date of application: __________NMOHC Physician_________________ MR#____________ Are you receiving assistance with chemotherapy drugs? ( )Yes ( )No Is this your first application for patient grant? ( )Yes ( )No I understand that completion of this application does not guarantee assistance from the Foundation. Grants are at the sole discretion of the NMCCF Patient Assistance Committee. In order to be considered, all supporting documents showing income and bills outstanding must accompany this application.
_________________________________________________________________________________ Name: ____________________________Sex: M F Marital status:___ Age____Date of Birth: ______ Address: __________________________________________________________Apt#: ___________ City: _________________________County_________________ Zip: ________________________ Telephone: __________________________________ Diagnosis: ____________________________ Financial Information Number of Persons in Household: ____________ Ages of dependent children__________________ 1. Please list all sources of income per month in your household: Salary: ___________ Work: PT/ FT On disability from work_______ Pension or retirement: ___________ Social Security Retirement or disability : ________ Notes: Unemployment or general assistance: __________ Child support or alimony: ___________________ Other: TOTAL MONTHLY INCOME: $___________________________ 2. What are your monthly expenses? What has changed with your financial situation because of your diagnosis? (please list and describe below-) Rent/House payment: __________Utilities:________
_______________________________Car payment: _______Insurance:___________Groceries:______ Other:________________________________________________________________________________ 3. Savings and Other Financial Resources: Checking account: Savings account: Stocks or bonds: Other Assets:
_______ _______ _______ _______
401 K or IRA accounts: Property other than home:
_______ _______
TOTAL RESOURCES: $________________________________ INITIALS OF PATIENT________________________________________
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Primary Insurance: _________________________Secondary Insurance: ______________________ Page 1
D E S C R I PT I O N O F FI N A N CI A L NE E D ( W h y a r e y o u r e q u e s t i n g a g r a n t f r o m t h e N M C a n c e r Center Foundation?)__________________________________________________________
Please list your most urgent non-medical financial needs (for example: PNM bill $203.00) and attach the corresponding bills to this application. Item
amount of request
(completed by/ signature)
________________________________
$_________________
___________________
________________________________
$_________________
___________________
________________________________
$_________________
___________________
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$---------------------------
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TOTAL AMOUNT OF REQUEST: $__________________________________
I attest that the above financial information is correct and complete to the best of my knowledge. I further understand that if there are any significant changes to the information provided on this application form I have a responsibility to notify New Mexico Cancer Center Foundation Patient Grant Program. Release of information: I authorize NMCCF to use and disclose my confidential medical records and financial information to the NM Cancer Center Foundation grant review committee and board for the sole purpose of reviewing, finalizing, and carrying out the disbursement of patient grants. This confidential information will not be released to any other parties. I authorize NMCC to release information to the NMCCF for this purpose. All grants are confidential to both the applicant and organization. If I receive financial assistance, I agree not to discuss the amount received from the Foundation to anyone outside the NMCCF. INITIALS OF PATIENT________________________________________
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This area below for mortgage, rent or car payments: Date: ____________________________
RE: Account #_____________________Account Name:____________________________________
To Whom It May Concern: Mr/Mrs/Ms ________________________ has applied for assistance with our Foundation for payment of their bills. We therefore request information from you as to the status of this account. The parties above agree to allow us to receive this information.
Sincerely, New Mexico Cancer Center Foundation 4901 Lang Ave, NE Albuquerque, NM 87109 www.nmcancercenterfoundation.org Ph (505) 828-3789 Fax: (505) 857-8480 Account holder signature________________________________Date:______________________
Patient/ Guardian Signature: _____________________________Date: _____________________ PLEASE NOTE: Please remit to the NMCCF in person, by mail or fax. For questions about your application, please call 505-828-3789 or speak with your NMCC Financial Counselor Please include all pertinent non-medical bills and income verification. Grant requests are routinely reviewed each month. The NMCCF grant committee has the discretion to prioritize and award grants based on patient need and available funding. We fund essential needs for applicants who are in active treatment for cancer/and or serious hematologic disorders We ask that you do a good deed for another in need when the opportunity presents itself.
INITIALS OF PATIENT________________________________________
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