Patient Assistance Fund - Request Form

The BMT InfoNet Patient Assistant Fund (PAF) assists patients and caregivers with living expenses during treatment.

Grants are $100-$200. We cannot accommodate larger grant requests.

Who is eligible for Assistance

Patients who in the past 12 months, have had
- an autologous transplant
- an allogeneic transplant with a related donor
- CAR-T therapy
Patients with graft-versus-host disease who are at least 12 months post-transplant

Application Process:

Application for funds must be completed by a social worker or transplant center personnel who certifies that the patient is in need of financial help
Please wait until day one of transplant prior to submitting application
ALL sections of the application form must be completed in order to be considered
If you have questions, please call 888-597-7674 or email Marsha at marsha@bmtinfonet.org

Evaluation/Decision

Patient and Transplant personnel will be notified via email when application is received.
Fully completed applications will be reviewed within two weeks of receipt. Incomplete applications will delay review.
Applicants and transplant personnel will be notified via email of the decision following review.

Disbursement of Funds

Funds will be dispersed in the form of a check made out to the patient or caregiver and mailed to address indicated on form.

Please complete the following application with as much detail as possible with the patient/caregiver. Failure to complete the application in full will result in delay of review and funding.

Patient or Parent/Guardian requesting Funds

This area is to be used for Patient or Parent/Guardian Requesting Funds.

First Name of Patient or Parent/Guardian Requesting Funds *

Last Name of Patient or Parent/Guardian Requesting Funds *

Home - Street Address *

Home - Street Address Line 2

Home - City *

Home - State

Home - Postal Code *

Email: We strongly encourage you to include an email for adult requesting funds

Birth Date - for Adult Requesting Funds *

Month

Day

Year

Relationship to Patient *

Relationship Other

Home - Phone Number *

Cell - Phone Number

If the person who is requesting the funds is not the patient. Please provide the following:

Patient's First Name

Patient's Last Name

Patient's Gender

Patient's Birthdate

Month

Day

Year

Diagnosis *

Type in disease to see list or select Other and complete the diagnosis description.

Diagnosis Description

If you did not see your Diagnosis on the drop down list or have additional information on the disease, please provide this information.

Primary Language Spoken in the home

What type of therapy did the patient have *

Bone Marrow/Stem Cell Transplant

CAR-T Therapy

Transplant Info

Date of Most Recent Transplant *

Month

Day

Year

Patient Age at time of (MRT)

Transplant Type (MRT) *

Donor type (MRT)

Type of cells used (MRT) *

Match Criteria (MRT) *

Transplant Center Formal Name (MRT) *

CAR T-cell therapy

Date of CAR-T

Month

Day

Year

CAR-T Type

Patient Age at time of CAR-T

Type of CAR-T Therapy

Other Type of CAR-T Therapy

Formal Center Name for CAR-T

Grant

People utilizing funds *

Indicate name and relationship of all people in household and any additional people who will utilize the funds.

Provide details why funding is needed. *

Include patient's current medical, living, family and financial situation. Please send additional information by email to marsha@bmtinfonet.org or fax to 847-433-4599.

Itemize all SOURCES and AMOUNTS of current monthly household income *

Please include income of ALL members of the household. Include the amount of: Wages, Investment income, SSI, Disability payments, etc.

Amount Requested * $

Has the patient applied for funding from other organizations? *

If Yes, list other organizations applied to and amount received

If patient is not awarded funds, how will s/he cover the expense? *

Will the check be send to a different address?

If the applicant is requesting the check to be sent to a different address than the home address, please provide the full address below.

Person to whom grant should be sent and relationship to patient

Gift - Street Address

Gift - Street Address Line 2

Gift - Street Address Line 3

Gift - City

Gift - State

Gift - Postal Code

Gift - Postal Code Suffix

+4 digits of Zip Code

Transplant Center Staff Person Contact Information and Verification

First Name *

Last Name *

Degree/License *

Position at Transplant Program *

Phone Number *

Transplant Center Staff - Email *

Name of person making this affirmation and the date *

I affirm that the information provided in this application is true and complete, and I am recommending this patient for financial assistance.

Leave this field blank

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Patient Assistance Fund - Request Form

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The BMT InfoNet Patient Assistant Fund (PAF) assists patients and caregivers with living expenses during treatment.

Caregiver's Role

Children and Transplant

Graft vs. Host Disease