::: Rofeh Cholim Cancer Society :::::

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Dear Applicant, Please read and follow instructions carefully.

RCCS was established primarily to pay for the health insurance premiums of cancer patients. (RCCS does not assist in paying for co-payments, deductibles, doctor visits, etc.)

Please complete and mail the application to the address above along with the following supporting documentation:

1) Patient’s medical info. (Diagnosis, prognosis, pathology report)
2) Attestations from clergyman with whom patient is affiliated.
(Must have signature and notarization)

Upon receipt of your complete application, our Board of Application Approval will evaluate the application and inform you of patient’s eligibility.

IMPORTANT: APPLICATIONS WILL NOT BE CONSIDERED UNLESS THE ENTIRE APPLICATION IS COMPLETE AND ALL OF THE SUPPORTING DOCUMENTATION IS ENCLOSED.

WITH BLESSINGS FOR A SPEEDY AND COMPLETE RECOVERY.

Your Information

First Name	Last Name	Sex	DOB	Age	SS#
		Male Female

Address		Apt #	City / State	Zip	Home Phone	Mobile Phone

List all your children, including those married or not married or not living at home


	Name	Age	Phone		Name	Age	Phone
1				6
2				7
3				8
4				9
5				10

Employers/Insrurance Info if patient is dependent, parents please complete

Are you self employed	Employers Name	Company Name
Yes No

Company Contact	Tel	Address

City	State	Zip	Name of insurance carrier	Policy #

What kind of coverage	Coverage EFF Date	Monthly Premium AMT
HMO POS PPO Single Family Couple Parent / Child

Do you have have medicaid - medicare or any other insurance / policy	Coverage EFF Date	Monthly Premium AMT

Spouse info / Parent Info

Parent or sopuse name	Is spouse employed	Employers Name
	Yes No

Company Name	Tel	Family gross monthly income

Address	City	State	Zip

Family care physician (doctor familiar with patients current condition )	name	Address	Tel

Diagnosis DIAGNOSIS (attach diagnosis, prognosis, and pathology report)

Two close relatives and responsible family members other than spouse parents & children

Relatives Name	Address	Phone	Relationship To patient

Two clergymen / CSW's who knows patient well:

Clergy Name	Address	Phone	Relationship To patient

How did you hear about RCCS?:

Comment?:

I AUTHORIZE RCCS AND\OR ANY OF THEIR REPRESENTATIVES TO OBTAIN ANY AND\OR ALL MEDICAL INFO. ENCLOSED THE ABOVE APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE
Signature of patient or guardianDate