Online Application - Hope Foundation

Consent to Begin Online Application

Provider Information

Facility/Practice Name:(Required)

Physician Name:(Required)

Patient Navigator, Social Worker, or other Case Manager Name (if applicable):

Address:(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone:(Required)

Fax:

Number of Miles Traveled Round Trip for Each Visit:(Required)

Supporting Documentation

If you have Supporting Documentation in electronic format available, you may upload here to submit with your application. If not available please email (information@ncshopefoundation.org), fax (402-691-1699) or mail (17201 Wright Street, Suite 200, Omaha, NE 68130) to the Foundation office. A member of your medical team must complete the Health Statement Form using the link provided above. Your submitted application will be processed once the completed Health Statement, Income documentation, and Expense Verification documents have been received.

Income Documentation

You must upload a copy or copies of supporting documentation to verify income, which include: Most recent Income Tax Return; Most recent W-2; Most Recent Pay Stub(s); Social Security award confirmation letter; Copy of Medicaid Card; other Medicaid verification. If you do not have supportive documentation, but are receiving financial support/assistance from other sources, please complete the Statement of Assistance/Support form using the link provided above. If you do not have supportive documentation, and DO NOT have income from other sources, please complete the Statement of No Income form using the link provided above.

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Expense Documentation

You must upload a copy or copies of documentation that verifies the expense(s) for which you're seeking assistance. Acceptable documents include: Housing: Mortgage Statement or Rental Agreement or receipt of monthly payment Car loan agreement or receipt of monthly payment; Utilities: Gas/heat, water and electricity bill; Documents must be in applicant's, spouse's, or legal partner's name.

Drop files here or

Max. file size: 300 MB.

Supplemental Information

How did you hear about NCS Hope Foundation?(Required)

Please briefly elaborate on your individual situation of need.(Required)

Would you be willing to have your story featured on our website and social media channels, with your photograph and/or a video for the purpose of helping others learn about our Foundation?(Required)

Yes

No

Authorization

Patient Signature (type your name)(Required)

Date(Required)

Patient Grant Application

By filling out the online application, you are acknowledging you have read and understand the
Grant Restrictions, HIPAA guidelines, and Income Requirements.

Patient Grant Application

Consent to Begin Online Application

General Information

Patient Information

Patient Demographic Information

List Total Household Gross Monthly Amounts From All Sources

Insurance Information

Provider Information

Supporting Documentation

Supplemental Information

Authorization

Our Sponsors

Patient Grant Application

By filling out the online application, you are acknowledging you have read and understand the Grant Restrictions, HIPAA guidelines, and Income Requirements.

Patient Grant Application

Consent to Begin Online Application

General Information

Patient Information

Patient Demographic Information

List Total Household Gross Monthly Amounts From All Sources

Insurance Information

Provider Information

Supporting Documentation

Supplemental Information

Authorization

Our Sponsors

By filling out the online application, you are acknowledging you have read and understand the
Grant Restrictions, HIPAA guidelines, and Income Requirements.