|
B T E R |
Bio-Therapeutics
Education & Research
Foundation |
Application for Patient
Assistance Grant
Please
complete this form and return it to any of the addresses above. Awardees are
eligible for subsidy of biotherapy products or free materials, depending upon
individual needs and available resources.
By
signing this form, the applicant (patient/representative) agrees to the terms
of this grant, including the anonymous tracking of results of this
program.
The applicant also grants
permission to their health care provider, insurance company,
and all others
involved with their health care,
to release the information necessary to
complete this application.
Unless
this box is checked [_],
the applicant also grants permission to be included in a registry held by the
BTER Foundation,
for the purpose of contacting applicants about relevant
studies and opportunities.
Personal
information is not sold or distributed in any way. Programmatic and anonymous
clinical information may be analyzed, summarized, and/or published. Contact the
BTER Foundation for any questions related to this Program.
______________________________ ____________________________
___________
Patient
Name (printed)
Signature Date
1.
Patient demographics and financial information -
Name of
patient:_________________________________________
Age:_____ Gender:_____
Address:
________________________________________________________________________
City:
______________________________
State:
_____ Zip code: __________
Phone: ____________________
Fax: ____________________ E-mail: ____________________
Insurance carrier (check all that
apply):
[_] Medicare
[_] Medicaid
[_]
HMO:
[_]
Other: _________________________
[_] PPO [_] None
Approximate annual income:
[_]
<
$10,000/year
[_]
$10,000
- 25,000
[_]
$25,000
- 50,000
[_]
$50,000-75,000
[_]
$75,000
- 100,000 [_]
>
$100,000
Amount
of support requested ( [_] estimated
/
[_]
actual /
[_] unknown; therapy not
complete): _____
For
the following services:
Biotherapeutic
supplies ([_]
maggots /
[_]
leeches (not currently
available)
/
[_]
other:
______________)
Other
supplies or services: __________________________________________________
_________________________________________________________________________
Has
therapy already begun? _______
Completed? _______
Duration
or number of treatments ( [
_]
estimated /
[_]
actual): ________
2. Care
provider information -
Physician:
_____________________________________________________________________________
Facility:
_______________________________________________________________________________
Address: ______________________________________________________________________________
City:
_____________________________________
State: _________
Zip code: _________________
Name of
contact:____________________________ Phone:____________
Fax:__________________
3.
Clinical Information -
Type of wound:
__________________________________________________________________________
_______________________________________________________________________________________
Reason for selecting biotherapy:
____________________________________________________________
_______________________________________________________________________________________
Treatments previously tried:
________________________________________________________________
_______________________________________________________________________________________
Alternative therapy if biotherapy
not available: __________________________________________________
_______________________________________________________________________________________
Anatomic site of treatment:
_________________________________________________________________
Underlying medical conditions /
illnesses: ______________________________________________________
_______________________________________________________________________________________
4.
Name and signature of person(s) completing this form
______________________________ __________________________________ ___________
Name
(printed) Signature Date
______________________________
Relationship
to Patient
“The BeTER
Foundation”
A public charity supporting
patient care, education, and research in biotherapy and symbiotic medicine