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Financial Assistance Application

Financial Assistance

Please complete this form with your hospital social worker to apply for financial assistance. 

You are eligible if:
- You live in OR are treated in Connecticut
- OR are treated at Maria Fareri Children's Hospital OR Baystate Children's Hospital
- AND the patient is under the age of 26

We offer non-medical financial, food, and transportation aid, including, but not limited to, mortgage, rent, utilities, and transportation. Other expenses are reviewed on a case-by-case basis. We do not provide support for medical expenses. Your application must be completed fully, demonstrating the need for financial assistance and providing verifiable information. 

By filling out this form, you consent to non-identifying information being included in grants, reports, and publicity. If you require assistance filling out this form, call our office at (203) 663-6893

Completion of our form does not guarantee approval.

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FINANCIAL ASSISTANCE APPLICATION
Month
/
Day
/
Year
Information About The Patient
First Name *
Middle
Last Name *
Patient's Gender
Month
/
Day
/
Year
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Month
/
Day
/
Year
Is the patient currently in active treatment for cancer?
Is the patient a Connecticut resident?
Patient's Ethnicity
Information About The Family
Primary Parent/Guardian (G1)
What is your relationship to the patient?
First Name *
Middle
Last Name *
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
ext Extension
Secondary Parent/Guardian (G2)
What is your relationship to the patient?
First Name
Middle
Last Name
Country
Address Line 1
City
State/Province
Postal Code
ext Extension
Financial Worksheet
Do parents/guardians live together?

If both parents/guardians live together, complete this section for the household.
If parents/guardians live separately, provide G1 information here, and also complete the G2 section that follows. 

Household/G1 Estimated Monthly Expenses
Household/G1 Estimated Monthly Income
Guardian 2 Financial Worksheet

 This section must be completed for second parent/guardian if both do not live together. If second parent/guardian does not provide support to the child skip to next section.

G2: Estimated Monthly Expenses
G2: Estimated Monthly Income
What type of assistance do you need?
INFORMATION ABOUT YOUR BILLS

Please scan your bill and email to info@thecircleofcare.org or fax to (203) 907-1352

Release and Statement of Confidentiality

In consideration for the receipt of any financial assistance or medical equipment that Circle of Care may provide to the applicant and/or the child, applicant agrees on behalf of applicant and the child to release Circle of Care and hold it harmless from any loss, liability, damage, cost or expense arising out of any claim or suits which may be brought or made which in any manner relates to the assistance or equipment provided to the applicant and/or the child as a result of this application. Circle of Care agrees to keep confidential all personal information, records, data, and files of any nature provided to it as a result of applicant’s request for assistance or medical equipment (the “Confidential Matters”). The undersigned acknowledge and agree that all non-identifying demographic information provided in the application may be used by Circle of Care for funding, grant and other similar purposes. Circle of Care agrees not to disclose any Confidential Matters without the prior written consent of applicant.

Applicant acknowledge and agree that Circle of Care may hereafter contact the child’s physician and/or social worker to verify any or all of the information from the application, including but not limited to the child’s diagnosis.

*REQUIRED if a second guardian is involved

Filling in your name above represents your authorized signature and your desire to have your application submitted to Circle of Care for review.

Contact Us

Phone 203.663.6893
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