B T

 E R

 

 Bio-Therapeutics   Education  &  Research  Foundation

 

36 Urey Court, Irvine,  CA  92617    ~   Phone: 330-644-0217 / Fax: 949-679-3001   ~    www.BTERFoundation.org

 

 

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