MEDICAL GRANT APPLICATION FORM

Personal Details

Name of the Patient Mr./Mrs./Ms./Master (if other than applicant)

Treatment Details

Family Members Details

Family Member 1 :
Family Member 2 :
Family Member 3 :
Family Member 4 :

Please give details regarding financial assistance sought from other trusts / organizations:

01
02
03
04
05

INSTRUCTIONS

  1. Medical grant is open only to Indian citizens residing in India.
  2. Applications for the Medical grant should be submitted either by the patient or by the patient’s immediate family member (father/mother/husband/wife/son/daughter/sister/brother.)
  3. The applicant for the Medical grant should be diagnosed with breast complaints requiring intervention as deemed necessary by your oncologist/ breast specialist.
  4. If the application form is accepted, the payment will be done after the commencement of the treatment (before discharge). No payment or financial assistance will be provided after discharge and no money will be reimbursed after the treatment.
  5. There is a maximum amount which will be provided by the trust beyond which, the applicant will need to arrange funds by themselves.
  6. Please note that, application / medical form received after the patient is discharged from the hospital will not be accepted by the Trusts.
  7. Incomplete forms will be rejected and no correspondence will be entertained in this regard.
  8. Submitting an application form to the Trust does not guarantee a Medical Grant from the Trusts. The Trusts’ decision to award medial grants, or otherwise, will be informed to the applicant. No explanation whatsoever would be given if the application is rejected.
  9. Original bills / receipts from hospital should be submitted upon request. Duplicate bills / receipts / certificates from the hospital will not accepted.
  10. For cases that are declined, original bills will be returned; however, other documents will be retained by the Trusts.
  11. The Trusts do not have any intermediaries / agents. Applicants are advised to beware of such individuals that claim to represents the Trusts and demand a share from the grant, if sanctioned. In case any such demands are made, applicants are requested to kindly bring the matter to the notice of the Secretary & Chief Accountant, immediately.
  12. Apart from the above instructions, it is hereby informed that the decision of the Trustees would be final and binding on all matters and on all persons pertaining to the application.
  13. Applicants can submit the medical application form in OPD or send by email to contact@ucbreastfoundation.org  Missing supporting documents, if any, should be submitted within 2 weeks from receiving the request for submission of the same (the Trusts may request for supporting documents through phone call / SMS / post). If the missing documents are not submitted within 2 weeks, the application will be closed and no further correspondence on the matter shall be entertained.
  14. Once the application has been submitted, you may have a home visit by our staff.
  15. Application from with incomplete / manipulated / false information, with an intention to mislead the Trusts, shall be treated as void and legal action will be taken as seemed necessary.
  16. Application form for a Medical Grant is available on ucbreastfoundation.org and in the outpatient department of  the hospital.
  17. CHECK LIST attached.

MANDATORY DOCUMENTS:

  1. Photo identity proof of applicant and patient (Any one from the list below)
    1. Pan Card
    2. Aadhar Card
    3. Voter ID card
  2. Address proof (Present or permanent address) (Any one from the list below)
    1. Ration Card
    2. Aadhar Card
    3. Voter ID card
  3. Latest Income Proof of all earning members
    1. If Salaried – Latest Income Tax Return/Latest Salary Slip/ Income Certificate
    2. If Pensioner – Pension Passbook with last one year’s entries.
  4. Letter from the Employer of all earning members mentioning whether the patient is eligible for any kind of medical assistance for the family. If not, then a letter from the employer to the effect mentioning the same.

SUPPORTING DOCUMENTS:

  1. Cancelled Check from patient’s bank account OR Applicant’s bank account (Cheque from applicant’s bank account acceptable only when the patient is minor).
  2. A detailed estimate of the investigations, treatment and procedure required for patient should be submitted prior to the commencement of the treatment.
  3. If original bills are submitted to TPA / Insurance company, then a letter from them on their letterhead mentioning the data and giving details: (i) the amount Insured; (ii) amount of original bills submitted to TPA/Insurance Company; (iv) Name and designation of the authorized signatory along with the rubber stamp of the Insurance company.
  4. If claim is under process, please attach photocopy of the Mediclaim policy
  5. If the treatment is ongoing or yet to commence, please attach a copy of the treating Doctor’s certificate stating ailment, treatment advises and the and the break-up of the estimated cost of treatment
  6. If payments are made by cheque and credit/debit card, kindly submit the copy of Bank Passbook/Statement showing the transaction
  7. Attach list of individual donors & trusts applied, sanctioned and grants received
  8. Trusts may ask for additional documents at any point during the application processing.

Date

Status of application

Signature
(This field should be filled by the trust)

MEDICAL GRANT APPLICATION FORM

A. Personal Details

Applicant's Name:

-

Patient's Name :

- - -

Age :

-

Sex :

-

Patient's PAN Card :

-

Patient’s relation to Applicant:

-

Contact Number:

+91___________

Email:

abc@gmail.com

Correspondence address:

1698 Coventry Court Baton Rouge LA Louisiana

Permanant address :

1698 Coventry Court Baton Rouge LA Louisiana

B. Treatment Details

Name of the Hospital:

-

Ailment:

-

Treatment:

-

Total Cost of treatment (estimated/incurred) (In Rs.):

-

Family /Personal Contribution (In Rs.):

-

Mediclaim received /eligible from insurance/employer company (In Rs.)

-

Medical Reimbursement from Employer (In Rs.)

-

Have You and /or any of your family members ever applied to the UC BREAST FOUNDATION? Yes /No
If Yes, please give details:

The US address provided on this page was randomly generated. All these generated addresses covering all cities and states in the United States. You can specify a state, city or zip code to generate a specific address. Please note that although these randomly generated addresses have the correct format, they are not real. They are only generated according to the correct and complete address format. You can enter these address information in some insecure websites to protect your real information from being leaked.

Total family Income (In Rs.) :

-

Family Details:

Sr.No. Name of Family Member Relationship to patient Age Occupation Monthly Income
1 - - - - -
2 - - - - -
3 - - - - -
4 - - - - -

Please give details regarding financial assistance sought from other trusts / organizations:

Sr. No. Name of trust / organization Applied on Amount sanctioned or to be considered / OR refused, pending, any other
1 - - -
2 - - -
3 - - -
4 - - -
5 - - -

Any other information :

-The US address provided on this page was randomly generated. All these generated addresses covering all cities and states in the United States. You can specify a state, city or zip code to generate a specific address. Please note that although these randomly generated addresses have the correct format, they are not real. They are only generated according to the correct and complete address format. You can enter these address information in some insecure websites to protect your real information from being leaked.

I declare that the above facts stated/mentioned and particulars given by me are true and correct.

Date
Signature of the applicant
Signature of the patient

Application received on:

(This Field should be filled by TRUST)

Note: In case of thumb impression, please get it attested by the authorized person.

INSTRUCTIONS
  1. Medical grant is open only to Indian citizens residing in India.
  2. Applications for the Medical grant should be submitted either by the patient or by the patient’s immediate family member (father/mother/husband/wife/son/daughter/sister/brother.)
  3. The applicant for the Medical grant should be diagnosed with breast complaints requiring intervention as deemed necessary by your oncologist/ breast specialist.
  4. If the application form is accepted, the payment will be done after the commencement of the treatment (before discharge). No payment or financial assistance will be provided after discharge and no money will be reimbursed after the treatment.
  5. There is a maximum amount which will be provided by the trust beyond which, the applicant will need to arrange funds by themselves.
  6. Please note that, application / medical form received after the patient is discharged from the hospital will not be accepted by the Trusts.
  7. Incomplete forms will be rejected and no correspondence will be entertained in this regard.
  8. Submitting an application form to the Trust does not guarantee a Medical Grant from the Trusts. The Trusts’ decision to award medial grants, or otherwise, will be informed to the applicant. No explanation whatsoever would be given if the application is rejected.
  9. Original bills / receipts from hospital should be submitted upon request. Duplicate bills / receipts / certificates from the hospital will not accepted.
  10. For cases that are declined, original bills will be returned; however, other documents will be retained by the Trusts.
  11. The Trusts do not have any intermediaries / agents. Applicants are advised to beware of such individuals that claim to represents the Trusts and demand a share from the grant, if sanctioned. In case any such demands are made, applicants are requested to kindly bring the matter to the notice of the Secretary & Chief Accountant, immediately.
  12. Apart from the above instructions, it is hereby informed that the decision of the Trustees would be final and binding on all matters and on all persons pertaining to the application.
  13. Applicants can submit the medical application form in OPD or send by email to contact@ucbreastfoundation.org  Missing supporting documents, if any, should be submitted within 2 weeks from receiving the request for submission of the same (the Trusts may request for supporting documents through phone call / SMS / post). If the missing documents are not submitted within 2 weeks, the application will be closed and no further correspondence on the matter shall be entertained.
  14. Once the application has been submitted, you may have a home visit by our staff.
  15. Application from with incomplete / manipulated / false information, with an intention to mislead the Trusts, shall be treated as void and legal action will be taken as seemed necessary.
  16. Application form for a Medical Grant is available on ucbreastfoundation.org and in the outpatient department of the hospital.
  17. CHECK LIST attached.

MANDATORY DOCUMENTS:
  1. Photo identity proof of applicant and patient (Any one from the list below)
    1. Pan Card
    2. Aadhar Card
    3. Voter ID card
  2. Address proof (Present or permanent address) (Any one from the list below)
    1. Ration Card
    2. Aadhar Card
    3. Voter ID card
  3. Latest Income Proof of all earning members
    1. If Salaried – Latest Income Tax Return/Latest Salary Slip/ Income Certificate
    2. If Pensioner – Pension Passbook with last one year’s entries.
  4. Letter from the Employer of all earning members mentioning whether the patient is eligible for any kind of medical assistance for the family. If not, then a letter from the employer to the effect mentioning the same.
SUPPORTING DOCUMENTS:
  1. Cancelled Check from patient’s bank account OR Applicant’s bank account (Cheque from applicant’s bank account acceptable only when the patient is minor).
  2. A detailed estimate of the investigations, treatment and procedure required for patient should be submitted prior to the commencement of the treatment.
  3. If original bills are submitted to TPA / Insurance company, then a letter from them on their letterhead mentioning the data and giving details: (i) the amount Insured; (ii) amount of original bills submitted to TPA/Insurance Company; (iv) Name and designation of the authorized signatory along with the rubber stamp of the Insurance company.
  4. If claim is under process, please attach photocopy of the Mediclaim policy
  5. If the treatment is ongoing or yet to commence, please attach a copy of the treating Doctor’s certificate stating ailment, treatment advises and the and the break-up of the estimated cost of treatment
  6. If payments are made by cheque and credit/debit card, kindly submit the copy of Bank Passbook/Statement showing the transaction
  7. Attach list of individual donors & trusts applied, sanctioned and grants received
  8. Trusts may ask for additional documents at any point during the application processing.

Date

Status of application

Signature
(This field should be filled by the trust)

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