Patient Advocacy

Our patient advocacy staff will attempt to assist patient’s families that have any problems with insurance, Medicare, Medicaid, hospital billing departments, denial of payments, or any other similar issue. Please fill out the form below to request assistance.

Print and mail this Patient Assistance Application Form or fill out the form below.

Patient Information

First Name (required)

Date of Birth

Age (required)

Address

City

Zip

Phone

Fax

Last Name (required)

Sex
 M F

Race

Address (cont)

State (required)

Email (required)

Mobile

Another family member to contact if you cannot be reached:
Name:
Phone:
Did you search for a bone marrow donor,  NMDP Caitlin Raymond Registry
Is the mother pregnant?  yes no
Do you know about Cord Blood Transplant?  yes no
Do you want to collect Cord Blood?  yes no

Health Care Information

Hospital Information

Hospital Name

Phone

Address

Physician Information

Attending Physician

Phone

Fax

Address

Transplant Coordinator

Name

Fax

Phone

Insurance Information

Insurance Carrier

Address

Group#

Subscriber

ID#

Family Antigens – HLA type if available , please attach

Release Form

I, (Parent/Guardian name) release and permit National Children's Leukemia Foundation to view/use/release my child's ,(Patient's name), my and/or my family's medical information for any purpose NCLF sees appropriate.

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