THE KELLY SHIRES FINANCIAL ASSISTANCE PROGRAM OF THE QUEBEC BREAST CANCER FOUNDATION Detailed application instructions

Transcription

1 THE KELLY SHIRES FINANCIAL ASSISTANCE PROGRAM OF THE QUEBEC BREAST CANCER FOUNDATION Detailed application instructions 1. Program objective... p.2 2. Eligibility.... p.2 3. Eligible expenses p.2 4. Documents to include with your application.... p.4 5. Processing of applications for assistance p.5 6. Help with the application process.... p.6 Appendix A - To read if you are a social assistance recipient.....p.6 Appendix B - Some accommodation resources during cancer treatment...p.8 Appendix C - Support programs for persons with cancer from Régie de l assurance maladie du Québec (RAMQ).p.9 1

2 1. PROGRAM OBJECTIVE The Kelly Shires Financial Aid Program of the Quebec Breast Cancer Foundation provides temporary, emergency financial assistance to women and men living with breast cancer, in order to help relieve certain financial difficulties that often arise as a result of the disease*. 2. ELIGIBILITY The following criteria guide the Foundation and its approval committee in the application review process. 1. To be processed, applications must be complete, accompanied by the requested supporting documents and submitted to the Foundation by mail or electronically. Incomplete applications will not be reviewed until all required documents are received. 2. It is possible to apply from the moment a breast cancer diagnosis is received. The applicant must: be a Canadian citizen or permanent resident domiciled in the province of Quebec; be in one of the following situations: be either currently or imminently in active curative or palliative treatment (surgery, chemotherapy, radiotherapy); be in the first year of post-treatment recovery; if the application is related to complications from breast cancer, be in treatment or 3 years post-treatment. Examples: lymphedema treatment, purchase of a breastform, dental or vision care required as a result of breast cancer treatment. 3. To be eligible for reimbursement of certain living expenses (such as rent or groceries), the application must demonstrate reduced income compared to the period before the breast cancer diagnosis. *Although the Foundation wants to help as many people as possible within a reasonable time, money given must meet the limits of the budget allocated to this program annually. 3. ELIGIBLE EXPENSES A maximum of : - $1,000 may be allocated for each application for financial assistance. - 4 applications per calendar year can be requested - A lifetime maximum of $10,000 in assistance applies to each applicant. An assessment of your financial situation is made to confirm the eligibility of your request for the financial assistance program. Once the assessment is completed, the amount granted could differ from the requested amount. If you re receiving social assistance, certain conditions apply. Please see Appendix A. All expenses incurred either prior to diagnosis, or more than a year before they were submitted for reimbursement, are ineligible. 2

3 3.1 ELIGIBLE EXPENSES A) EXPENSES RELATED TO BREAST CANCER DIAGNOSIS AND ACTIVE TREATMENTS Medication related to breast cancer not covered by the Régie de l Assurance Maladie du Québec (RAMQ), group plans, private insurance plans OR the deductible on covered medications Transportation to/from recurring medical appointments or treatments related to breast cancer (e.g. volunteer driving fuel, taxi, bus) Parking related to medical appointments/ repetitive treatment related to breast cancer Food during medical appointments/ repetitive treatment related to breast cancer Childcare during medical appointments/treatment/recovery Accommodations during treatment, in order to stay closer to the treatment location Medical aide/housekeeper at home during active treatment related to breast cancer / convalescence Hair prosthesis (Maximum: $250/ prothesis), hat, scarf Precisions : If you re receiving social assistance, see Appendix A If you re receiving social assistance, see Appendix A Certain community organizations offer accommodations at modest cost near select treatment centres. For more information, see Appendix B Massage Therapy in Oncology / osteopathy A maximum of 10 sessions may be eligible B) EXPENSES RELATED TO A COMPLICATION OF BREAST CANCER These expenses could be eligible up to 3 years after the end of active treatment (chemotherapy or radiotherapy). Their eligibility depends on its assessment of your financial situation. Breastform/ breast prosthesis) (max: $500/each) / specialized undergarments (max: $80/bra) / specialized swimsuit Lymphedema treatment (physiotherapy, massage, lymph drainage) or lymphedema equipment (eg.: compression sleeve) Various consultations: psychology related to breast cancer (patient, spouse, child), nutritionist related to breast cancer, etc. Other possible expenses such as: vision or dental care related to a complication of breast cancer If you had a radical mastectomy, see Appendix C (External breastforms program - RAMQ) See Appendix C (Compression garments program for the treatment of lymphedema - RAMQ ) A maximum of 10 sessions may be eligible -Type of expense eligible only once; -A doctor s note must justify that the need is related to breast cancer. C) LIVING EXPENSES The applicant must : - be either currently or imminently in active curative or palliative treatment (surgery, chemotherapy, radiotherapy) or within the first year of recovery post-treatment, AND - be experiencing reduced income compared to the period preceding the breast cancer diagnosis (e.g. through loss of work). Rent/mortgage Groceries Utilities (Hydro-Québec, Internet, etc.) Telephone (max: $50/bill) If you re receiving social assistance, see Appendix A 3

4 3.2 EXAMPLES OF INELIGIBLE EXPENSES Credit card bills or other debts; Automobile repairs/tires; Cable or other television bills; Home, auto, life or other insurance premiums; Medications and expenses that are not in your name; Naturopathic therapy and expenses related to the purchase of vitamins and/or supplements, unless prescribed by your physician; Other expenses: alcoholic beverages, lottery tickets, pet food, cigarettes. Expenses related to care received at private clinics, if such services are available through the public healthcare system. 4. DOCUMENTS TO INCLUDE WITH YOUR APPLICATION To ensure that your application is processed as fast as possible, you must include the following documents (we may request additional documents): FOR THE FIRST APPLICATION: 1. A copy of your proof of Canadian citizenship or permanent residency in Quebec, such as your birth certificate, baptismal certificate or Canadian citizenship card. 2. Signature of page 2 and 3 of the application form for financial assistance from your oncologist, nurse navigator or social worker. 3. A copy of the provincial income tax assessment for the most recently completed fiscal year for the household including you and your spouse (if applicable) and any other adult residing at the same address as you who is earning an income (if applicable) I. The notice of assessment is a document on blue paper sent to the taxpayer after the filing of a tax return; it confirms that the return was properly completed and filed II. A T4 slip is not sufficient to satisfy this requirement 4. Recommendation: if your breast cancer diagnosis was made more than a year ago, include the household s provincial income tax assessment for the fiscal year preceding your diagnosis, in order to give us a better understanding of changes in your financial situation that could have resulted from the breast cancer, if any. WITH ALL APPLICATIONS: 1. Proof of current income, such as: employment income, employment insurance, disability pension, retirement pension, social assistance, property income, interest income, etc.; 2. All detailed receipts (paper or digital) for expenses for which you are seeking assistance; 3. Signature of page 2 and 3 of the application form for financial assistance from your oncologist, nurse navigator or social worker if your initial application for financial assistance was submitted more than one year before your present request; 4. A copy of the provincial income tax assessment for the most recently completed fiscal year for the household including you and your spouse (if applicable) and any other adult residing at the same address as you who is earning an income (if applicable) if your initial application for financial assistance was submitted more than one year before your present request; 5. If the application concerns: a) Rent/mortgage: a copy of your current lease or loan contract; b) Transportation, food, childcare, accommodations for or during medical appointments and treatments: official documentation of the dates and times of your appointments/treatments. 4

5 5. PROCESSING OF APPLICATIONS FOR ASSISTANCE 5.1 How to apply: 1. Download the application form from our website: rubanrose.org/financial_assistance 2. Send your application and all required documents: 1. By to 2. By fax to By mail to: Quebec Breast Cancer Foundation The Kelly Shires Financial Assistance Program of the Quebec Breast Cancer Foundation 1155 René Lévesque Blvd. W., suite 1705 Montreal, Quebec H3B 3Z7 5.2 Processing time As soon as we receive your application, we will acknowledge receipt. If any documents are missing, the Quebec Breast Cancer Foundation will advise you as soon as possible. Once we have the complete file you will be notified of our decision within approximately 15 business days, including a cheque for any amount granted. Before submitting a second application for assistance, the first application must first be received (including all documents), processed and closed. 5.3 Confidentiality All personal information provided to the Quebec Breast Cancer Foundation will be handled in a confidential manner, and is protected under the Privacy Act (Canada). 6. HELP WITH THE APPLICATION PROCESS If you need help completing your application for financial assistance, do not hesitate to ask the oncology social worker at your hospital, your nurse navigator, or one of the organizations providing support to cancer patients in your region. The Kelly Shires Financial Assistance Program of the Quebec Breast Cancer Foundation can also provide help. Please feel free to contact us at: Tel.: soutien@rubanrose.org rubanrose.org/financial_assistance 5

6 APPENDIX A TO READ IF YOU ARE A SOCIAL ASSISTANCE RECIPIENT: To avoid duplication of services, the Foundation will not reimburse these fees to applicants recipients of social assistance, unless the recipients can provide proof that these fees could not be covered by social assistance: 1) Medication: The ministère de l Emploi et de la Solidarité sociale provides information on recipients of last-resort financial assistance to the RAMQ (Régie de l assurance maladie du Québec) who then registers these recipients in the public plan. When getting medication covered by the RAMQ at a pharmacy, recipients of last-resort financial assistance must show their claim slip and valid Health Insurance Card to receive the medication free of charge. 2) Transportation fees related to medical treatments: Social assistance grants a special benefit to cover transportation costs related to medical treatments. To obtain this benefit, the social assistance recipient who is undergoing treatment must submit a request for reimbursement to social assistance no later than on the last day of the following month, to ensure the request is taken into consideration. 3) Living expenses (rent, groceries, accommodation): Social assistance benefits are provided mainly to cover the recipients everyday living expenses. Since any surplus amount related to a reimbursement of living expenses could be deducted from the benefits granted to a social assistance recipient, the Foundation cannot reimburse these fees to applicants recipients of social assistance**. **If your situation shows that you have recently began receiving social assistance and you are now experiencing a drop in income due to breast cancer, you could be eligible to receive one single annual reimbursement for your living expenses from our financial assistance program, without it affecting your benefits (e.g.: rent, groceries, etc.). We encourage social assistance recipients to submit an application for financial assistance for expenses directly related to breast cancer (see page 2 of this document) to the Quebec Breast Cancer Foundation. We would then be in a better position to help you, and reimburse expenses deemed to be eligible, once a review of your file has been completed. For further information on conditions related to social assistance benefits, you may contact the ministère de l Emploi et de la Solidarité sociale, through the following contact details: Tel.: Website: 6

7 DID YOU KNOW THAT If you are working on a regular basis: When you get sick you can receive sickness benefits for up to a maximum of 15 weeks, even if you are on parental leave as per the Quebec Parental Insurance Plan (you get sick during the parental leave). If you are self-employed: You could be eligible to receive Employment Insurance Sickness Benefits. To obtain further information or to determine your eligibility, visit: or dial

8 APPENDIX B SOME ACCOMMODATION RESOURCES DURING CANCER TREATMENT Several community organizations offer affordable accommodations for patients and loved ones near select treatment centres; here is a partial list. Please feel free to contact us for more information. Fondation québécoise du cancer (Montreal, Sherbrooke, Trois-Rivières and Gatineau) / Tel: Canadian Cancer Society (Montreal) / Tel: Hôtel-Dieu de Québec (Québec) Tél. : Association du cancer de l Est du Québec (Rimouski) Tel:

9 APPENDIX C SUPPORT PROGRAMS FOR PERSONS WITH CANCER FROM RÉGIE DE L ASSURANCE MALADIE DU QUÉBEC (RAMQ) The Kelly Shires Financial Assistance Program of the Quebec Breast Cancer Foundation seeks to assist as many people as possible without duplicating other services. The following programs may be able to provide assistance: EXTERNAL BREASTFORMS PROGRAM RÉGIE DE L ASSURANCE MALADIE DU QUÉBEC (RAMQ) Persons covered under the Quebec Health Insurance Plan who have had a radical mastectomy are entitled, for each breast, to $200 to cover some or all of the cost of the purchase of a breastform. Every two years, on the anniversary of the mastectomy or the medical report, the person is entitled to an additional $200 to cover replacement of the breastform. Recipients of last-resort financial assistance are entitled to a supplement (maximum $100, if the cost of the breastform exceeds $200). Information: FINANCIAL ASSISTANCE PROGRAM FOR DOMESTIC HELP SERVICES RÉGIE DE L ASSURANCE MALADIE DU QUÉBEC (RAMQ) Persons using domestic help services provided by a domestic help social economy business that has been accredited for program purposes may receive financial assistance applicable against the hourly rate the business charges. There are two types of financial assistance: basic financial assistance of $4 for each hour of service rendered is granted to any eligible person, regardless of family income variable financial assistance of $0.60 to $9 for each hour of service rendered may be granted over and above the basic financial assistance, and is determined on the basis of an eligible person's family income and family situation. Covered services: Light housekeeping work, such as laundry, vacuuming, dusting, cleaning (refrigerator, bathtub, pantry, etc.). Heavy housekeeping work, such a major cleaning jobs and clearing snow from the main access to the residence. Cleaning clothes. Preparing non-diet meals. Shopping for groceries and running other errands. Information:

10 COMPRESSION GARMENTS PROGRAM FOR THE TREATMENT OF LYMPHEDEMA RÉGIE DE L ASSURANCE MALADIE DU QUÉBEC (RAMQ) Anyone covered by the Québec Health Insurance Plan who suffers from primary or secondary lymphedema is eligible for, once every 12-month period: one set of multi-layer bandages one compression garment one accessory for compression garments For each garment, accessory (rubber glove, sleeve donner, stocking donner, skin adhesive, etc.) and set of bandages, the program provides for a reimbursement of 75% of the total purchase cost, up to the maximum allowable amount. Recipients of last-resort financial assistance are entitled to a full reimbursement of the total purchase cost, up to the maximum allowable amount for recipients of last-resort financial assistance. Information: