Skip to main content
MENU

Financial Assistance

To apply for financial assistance, please complete this form with your hospital social worker. To be eligible, you must have a child in treatment at Yale New Haven Children's Hospital, Connecticut Children’s Medical Center or be a CT resident in treatment out of state. We offer financial, food and transportation aid paid including, but not limited to: mortgage, rent, utilities, gas and grocery debit cards. Other items are reviewed on a case-by-case basis. We do not provide support for medical expenses. Your application must be completed in full, demonstrating need and providing verifiable information. To be eligible for services, you consent to non-identifying information being included in grants, reports and publicity.

Completion of our form does not guarantee approval.

 - Español -

 

FINANCIAL ASSISTANCE APPLICATION
/
/
Information About The Patient
First Name
Middle Initial/Name
Last Name
Patient's Gender
/
/
Country
Address Line 1
Address Line 2
City
State
Postal Code
/
/
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 Initial/Name
Last Name
Country
Address Line 1
Address Line 2
City
State
Postal Code
Phone Number
ext Extension
Secondary Parent/Guardian (G2)
What is your relationship to the patient?
First Name
Middle Initial/Name
Last Name
Country
Address Line 1
City
State
Postal Code
Phone Number
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.

  • MBIA Foundation
    MBIA Foundation
  • J P Morgan Chase
    J P Morgan Chase
  • Northwestern Mutual
    Northwestern Mutual
  • Georgette Geller
    Georgette Geller