APPLICATION PAGE

*IF YOU HAVE ADDITIONAL PAPERWORK YOU WOULD LIKE TO SUBMIT WITH YOUR APPLICATION YOU CAN EMAIL application@miltshelpingmilts.com PLEASE PUT YOUR NAME IN THE SUBJECT LINE**

*If request help due to a medical condition, the MEDICAL INFORMATION section below must be filled out along with file a HIPPA release form. If you applied to MHSAA you must file a release authorization form and email both to the following email: application@miltshelpingmilts.com.

For your convenience click on form need to be redirected:

HIPPA FORM MHM RELEASE FORM

Name

First

Last

Alumni Name (if different from above)

First

Last

Did you apply to MHSAA Cancer Care or Helping Hands?

Yes* (please state date, decision, amount below)
No

* if yes

Relationship to MHS Alumni

Self
Spouse
Minor child residing at home*

Your child must be younger than 19 years old or be a full time student younger than 24 years old as of the end of the calendar year. There’s no age limit if your child is “permanently and totally disable”*** or meets the qualifying relative test. ***Your child is permanently and totally disabled if both of the following apply: The child cannot engage in any substantial gainful activity because of a physical or mental condition and it is medically determined that the condition has lasted or can be expected to last at least a year or lead to death.

Address

Street Address

City

City, State/Province/Region, Zip/Postal Code

HIS/MHS Class of

Spouse Name

Phone

Consent 1

I consent to the statement below

I certify that I have been diagnosed with medical condition and currently am in active treatment** or am unable to work due to a verifiable sequela(s)*** of the medical condition by a medical provider and that I have the following financial need (brief description below). **Active Treatment: Currently undergoing chemotherapy, surgery, or radiation therapy related to a medically documented condition.

If Financial Need Describe***For Medical Fill Form Below

Consent 2

I consent to the statement below

I understand that I am voluntarily disclosing my medical and/or financial related information for consideration by the Milts Helping Milts organization for the sole purpose of applying for donation. In addition to completing the required medical and financial forms, I understand that Milts Helping Milts may contact me and/or my financial institutions and/or my healthcare team to verify my medical diagnosis and financial need in order to evaluate my application. I acknowledge that the information disclosed pursuant to this application may be Subject to re-disclosure by the recipient and no longer may be protected by Subject E of the Regulations promulgated by the U.S. Department of Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 HIPPA”) relating to the privacy of individually Identifiable health information.

MEDICAL INFORMATION

EVERY FIELD BELOW MUST BE FILLED OUT IF ANY FIELD DOES NOT APPLY PLEASE PUT N/A.

Patient Name

Medical Diagnosis and/or sequelae

Date of original medical diagnosis

Date of recurrence/sequelae medical diagnosis

Medical Diagnosis Is Being

Actively Treated
Unable to obtain gainful employment due to sequela(e)

Treatment Facility or Facilities

its of Address

Current active treatment (include chemotherapy, surgery, and/or radiation therapy details) and/or documentation of sequelae and its impact on obtaining gainful employmnet (may email current comprehensive chart notes/theropy notes if desired)

Name/Title of attending Doctor/Oncologist, Oncology Nurse, or Social Worker

Printed Name/Title of Doctor/Oncologist

Oncology Nurse, or Social Worker

Hospital/Clinic Name

Address

Street Address

City State Zip

City, State/Province/Region, Zip/Postal Code

Email of Dr, Nurse or Social Worker

Phone Number of Dr, Nurse or Social Worker

All information provided will be partly used for determination of assistance. All decisions will be voted on by MHM Board Members. Your information will only be discussed with your authorized contacts.

***IF YOU HAVE ADDITIONAL PAPERWORK YOU WOULD LIKE TO SUBMIT WITH YOUR APPLICATION YOU CAN EMAIL application@miltshelpingmilts.com PLEASE PUT YOUR NAME IN THE SUBJECT LINE****

*If request help due to a medical condition, the MEDICAL INFORMATION section below must be filled out along with file a HIPPA release form. If you applied to MHSAA you must file a release authorization form and email both to the following email: application@miltshelpingmilts.com.

For your convenience click on form need to be redirected:

HIPPA FORM MHM RELEASE FORM

*IF YOU HAVE ADDITIONAL PAPERWORK YOU WOULD LIKE TO SUBMIT WITH YOUR APPLICATION YOU CAN EMAIL application@miltshelpingmilts.com PLEASE PUT YOUR NAME IN THE SUBJECT LINE**