The Patient Services Program provides funding for Medical and Non-Medical needs for individuals
suffering from leukemia, lymphoma, Hodgkin’s lymphoma, multiple myeloma, myelodysplastic
syndrome (MDS) and other malignant diseases of bone marrow. Those suffering from one of these
diseases, as confirmed by a qualified physician, may submit an application to the Foundation for review.  Patients seeking financial aid must currently be under a physician’s care. This program is restricted to Connecticut residents undergoing treatment in, or outside of Connecticut, and to non-residents being treated in Connecticut Hospitals. The guidelines for Medical Assistance funding and Non-Medical Assistance funding are as follows:

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MEDICAL ASSISTANCE:

Funding for Medical Assistance is intended to assist patients and their families, to defray the non-
insured cost of expensive treatments for blood related cancers.

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These funds cover the cost of medical services, medications specific to the patient’s disease beyond
insurance coverage, travel expenses for public transportation, personal auto at $.25 per mile, parking,
tolls, office visits and, under special circumstances, temporary accommodations for those receiving
treatment out of area.

Upon application approval, funding of up $1,500 will be available to the patient. After the initial $1,500
has been fully utilized, and following a 90-day waiting period from the date of the first application
approval, patients may apply for additional funding of up to $1,500, for a maximum of $3,000 per fiscal
year. Requests for Medical Assistance funding may only be submitted twice in the same fiscal year.

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NON-MEDICAL ASSISTANCE:

Funding for Non-Medical Assistance is intended to assist patients and their families to defray the non-
insured, non-medical expenses encountered while obtaining treatment for blood related cancers. The
non-medical expenses covered are:

Electric Bills
Gas/Propane/Oil used for home heating
Water Bills
Rent/Mortgage assistance will only be given if the patient has not received additional financial aid from
another social program, such as, but not limited, to Section 8 housing.

Upon application approval, funding of up to $1,000 will be available to the patient. Total funding of
$1,000 is limited to once per fiscal year, with a maximum of three times per patient, for a total of
$3,000. Requests for Non-Medical funding may only be submitted once per fiscal year.

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Program guidelines, please read entirely before filling out application

Applications are reviewed in the order received. Applications for Medical Assistance will receive priority
over applications for Non-Medical Assistance. First time applicants will receive priority over second
request applications. Applications must be completed in its entirety. Incomplete applications will be

returned to the patient for completion.  Applicants will be notified by mail if their request for financial
assistance has been approved.

Patients submitting an application must include copies of their current tax return form 1040 or 1040EZ
and copies of medical bills, utility bills or lease/mortgage with their application, along with a brief
synopsis detailing why financial aid is needed. Funding is available based on the patients’ financial needs
for Medical and Non-Medical assistance.

Funding issued for Medical Assistance and Non-Medical Assistance may not be combined, however,
patients may apply for assistance under either after funding for the first is approved (e.g., applying for
Non-Medical Assistance after receiving Medical Assistance and vice versa). Funding will only cover items
under each respective approved application, therefore, items covered under Medical Assistance as
outlined above may not be reimbursed as a Non-Medical expense and items covered under Non-
Medical Assistance as outlined above, may not be reimbursed as a Medical expense. If bills under each
are submitted incorrectly, the application will be returned to the applicant for revision.

Once an application has been approved, the funds ($1,500 for medical assistance and/or $1,000 for non-
medical assistance) will be held by the Foundation, earmarked for the patient. Funds will be disbursed as
receipts/bills are submitted. It is the Foundation’s preference to make payments directly to service
providers and will only look at applicant reimbursement as a second means of payment. For mortgage
funding, a copy of the applicant’s current mortgage coupon/payment stub with loan # and mailing
address must be provided. For rent funding, a copy of the applicant’s current lease, landlord’s name,
and billing address must be provided. For all other funding, copies of the actual bills the applicant wishes
to have paid must also be provided. These items must be submitted at least two weeks prior to their
due date, so that we may process and mail the payment to be received by their due date.

Funds not used within 12 months from the application approval date will no longer be available and will
be deposited back in to the general Program Services fund. However, should this occur, the patient may
submit another application at a later date.

Special requests for additional funding shall be determined by a vote of the Board of Directors.
Funding for Medical Assistance and Non-Medical Assistance is limited to expenses not covered by all
insurances and fund-raising activities for the patient. Any exceptions to the program must be approved
by a vote of the Board of Directors.

All applications submitted require approval by the Board of Directors or the Administrators appointed by
the Patient Services Committee. Program funding limits will be reviewed and set each fiscal year by a
vote of the Board of Directors.

Receipt of application does not guarantee awarding of funds.

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YOU CAN DOWNLOAD THE APPLICATION HERE