Safety Net

Financial Assistance Program

Program Overview

This is an “online grant program” for “reimbursable event related support” –meaning, the grant does not support unpaid expenses, only expenses validated with a current / original invoice & payment receipt for said expense.  Receipts are required to be submitted with the grant application.

Application Requirements

1. Application is complete and signed by both the patient’s guardian and the Recommending healthcare provider.

2. In the case of attached receipts and support documentation, we should receive the following:

  •  Transportation: Attach a description of required travel for treatment including treatment dates, to/from destination and either gas receipts for respective dates or mileage amounts for each specific reimbursement date being requested. If mileage is requested, we will reimburse at the approved IRS rate for medical mileage. We will either reimburse for mileage or gas receipts but not a combination of the two.
  •  Medical Supplies: Include description of supplies or equipment being requested and corresponding receipt evidencing payment of equipment.
  •  Medication: Include corresponding receipts for prescribed medication or over the counter medication needed. We will reimburse any out of pocket costs not covered by insurance.
  •  Insurance Co Payment and Deductibles: Attach receipts for payment of any co-payment and/ or deductibles either for doctor visits, hospital stays, or medical care incurred for patient.

3. All receipts should fall within the treatment dates shown in the application.

4. Household Income Information – Attach latest Income Tax return for said household.

Support Qualifications

Support is limited to the following reasons:

1. Durable home-based medical supplies/equipment/mobility aids

2. Medication -prescription and over the counter

3. Transportation costs to and/or from treatment

4. Insurance co-payments & out-of-pocket plan deductibles

Eligibility Requirements

  1. Patient must be currently undergoing or recently underwent treatment in relation to cancer.
  2. Patient must be a legal citizen of the USA and be under the age of 18 as of the day of treatment.
  3. Patient’s treatment must be validated (signature on application) by a licensed healthcare provider providing said treatment and by supporting parent/legal guardian.
  4. Financial needs will be assessed based on numerous factors.
  5. A family is allowed to apply for up to $1,250 with each application. Each family is eligible to apply twice with at least six months between application dates. The maximum grant to each family is $2,500.