Web: www.bcapfund.org, e-mail: bcapfund@bcapfund.org
A local charity serving Greater Tulsa
“Assisting Patients through Their Journey to Recovery”
Assistance Request Application
Revised 05.15
BCAP Mission Statement:
To assist Greater Tulsa breast cancer patients currently undergoing debilitative cancer treatments by providing
temporary financial assistance for basic needs such as rent/mortgage and utilities.
The basis for this critical assistance will come from corporate donations, private donations, grants and certain
fundraising efforts.
Patients are chosen through a selection process that addresses specific needs. Once a recipient is chosen, funds
will be disbursed directly to the vendor or supplier of these identified needs based on the availability of funds.
Our goal is to assist these patients in winning their battle against breast cancer. By diminishing financial stress
related to the basic needs of the family, the breast cancer patients can direct their energies more effectively to
the healing process.
Policy & Eligibility Guidelines for Assistance:
Our objective is to assist as many Greater Tulsa breast cancer patients as possible. To ensure this, we have
established certain policies and guidelines. (These guidelines will be reviewed and updated annually by our
Candidate Committee and Board of Directors).
General Requirements:
1. Must be a resident of Greater Tulsa (Adair, Cherokee, Craig, Creek, Delaware, Kay, Mayes, Muskogee,
Nowata, Okmulgee, Osage, Ottawa, Pawnee, Rogers, Tulsa, Wagoner and Washington Counties).
2. Must be currently undergoing breast cancer treatments. Treatments defined as Chemotherapy, Radiation ,
Surgery or within 90 days of surgery (Diagnosis Confirmation Form must be completed and signed by both
Patient and treating Physician).
3. Applications will be reviewed by BCAP’s Candidate Committee and must be approved by the Board of
Directors.
4. Applicants may re-apply for assistance every 90 days from the date of award notification. If denied,
patient may re-apply after 30 days from date of notification letter. Contact BCAP to re-apply.
P.O. Box 470065, Tulsa, Oklahoma 74147, A 501(c)(3) Organization
Web: www.bcapfund.org, e-mail: bcapfund@bcapfund.org
Procedure for Assistance Request:
1. Complete and submit the Application for Assistance Request Form and all required attachments.
Applications will not be considered complete and reviewed until ALL supporting documentation is received
or an explanation is received explaining any missing documents.
2. Complete the patient portion of the Diagnosis Confirmation Form and submit to your current treating
physician’s office. The doctor will send the Diagnosis Confirmation Form directly to BCAP.
3. The Candidate Committee will review all applications for assistance and the Board of Directors will make
final selection based on availability of funds.
4. Selected applicants will be notified within 10 days once assistance is approved.
5. Applications will only be accepted by MAIL. Please mail to P. O. Box 470065, Tulsa, OK 74147.
PATIENT CHECKLIST
Completed Application
Copies of Rental Lease or Mortgage Coupon
Copies of Most Recent Utility Statements
Last Pay Stub for Patient and Spouse/Significant Other
3 Months Checking & Savings Statements
Sign and Complete Disclosure of Protected Health Information
MAIL Application & Documents
Verify Doctor has Faxed in Diagnosis Confirmation Form
Feel free to black out any account numbers on your bank statements. Your name needs to be visible.
We will need to see account numbers on all bills presented. Additionally, for bills presented, the name and
service address must be visible.
P.O. Box 470065, Tulsa, Oklahoma 74147, A 501(c)(3) Organization
Web: www.bcapfund.org, e-mail: bcapfund@bcapfund.org
A local charity serving Greater Tulsa
Application for Assistance Request
Date
/
/
Applicant’s Name ______________________________________________ Date of Birth ______________
Mailing Address
County
Applicant email address:
Home Phone
Cell Phone
Other Phone
Currently employed? Y or N Where?
Hrs worked per week
Applicant’s Total Monthly Income
(Payroll, Investment, Social Security, Unemployment)
Other Household Income Y or N Source of Income & Amount
Number of Adults in Household
Explain
Number of Children in Household
Ages/Gender
Others in Household
Checking Accounts? Y or N How Many __
Estimated Balance _
Savings Accounts? Y or N How Many
Estimated Balance
Contact Person: (If Other than Patient)
Mailing Address:
Home Phone:
Cell Phone:
Other Phone:
P.O. Box 470065, Tulsa, Oklahoma 74147, A 501(c)(3) Organization
Web: www.bcapfund.org, e-mail: bcapfund@bcapfund.org
BCAP collects this information to comply with Federal rules requiring BCAP to provide this information when
applying for grant monies, and to assist in the continued effort of tracking diagnosis among ethnic groups to
increase awareness and education. BCAP does NOT use this information to make decisions about financial
assistance to our patients. BCAP prides itself on diversity and inclusion and will continue to assist ALL patients
who qualify. (You are not required to answer these questions)
☐
White not Hispanic
☐
Black not Hispanic
☐
Hispanic
☐
American Indian or Alaskan Native
☐
Asian or Pacific Islander
**Name of Mortgage Co/Landlord
Street Address
City & State
Amount of Mortgage or Rent
Zip
No. of payments past due
Account Number
Phone Number
**Name of Electric Company
Amt past due
Street Address
City & State
Account Number
Zip
Phone Number
**Name of Gas Company
Amt past due
Street Address
City & State
Account Number
Zip
Phone Number
**Name of Water Company
Amt past due
Street Address
City & State
Account Number
Zip
Phone Number
**Attach copies of recent mortgage/rent coupon, electric bill, gas bill and water bill
If selected for an award, in what order would you like any award applied (rent/mortgage, electric, gas, water)
1)
2)
3)
4)
P.O. Box 470065, Tulsa, Oklahoma 74147, A 501(c)(3) Organization
Web: www.bcapfund.org, e-mail: bcapfund@bcapfund.org
Please include a brief statement telling us about your personal situation. Include any information you feel
is pertinent to your application and why you need our help.
How did you hear about BCAP?
Please attach the following documents: Last Pay Stub (Patient and spouse/significant other)
Previous 3 months of checking/savings account
statements
I understand that my application cannot be processed until I have completed all of the documentation
and submitted it to the address noted on the bottom of this application.
By signing below, I agree that the information provided above and in the attachments is accurate to the best of
my knowledge. I further understand that my name and personal/financial information will be kept
confidential unless I give specific permission otherwise.
Applicant’s Signature: _
Date
/
/
P.O. Box 470065, Tulsa, Oklahoma 74147, A 501(c)(3) Organization
Web: www.bcapfund.org, e-mail: bcapfund@bcapfund.org
A local charity serving Greater Tulsa
Diagnosis Confirmation Form
Applicant’s Name:
Complete Mailing Address:
Date of Birth:
I hereby authorize
(Name of Current Treating Physician) to release or
disclose to B.C.A.P. my medical information pertaining to my current diagnosis and prognosis, surgeries and
treatments. I further authorize you to discuss with B.C.A.P. any confidential information with respect to my
medical condition or treatment and any confidential information with respect to my financial situation. I
understand the purpose of this disclosure is for use in pending application for financial assistance by B.C.A.P. I
understand that my name, personal, financial and medical information will be kept confidential unless I give
specific permission otherwise. This authorization will expire one year after the date of signature below.
Applicant’s Signature:
Date
/
/
Patient fills out top portion of form and gives to current treating physician
-----------------------------------------------------------------------------------------------------------------------------------Physician fills out bottom portion of form and fax form to BCAP at 918-932-2908
Type of Cancer:
Date of Initial Breast Cancer Diagnosis
Chemo Start Date
/
Radiation Start Date
/
/
/
/
/
Chemo End Date
/
Radiation End Date
Date of Surgery
/
/
/
/
/
/
Treating Physician Name:
Complete Address:
Phone Number:
Physician Signature:
Date
/
/
P.O. Box 470065, Tulsa, Oklahoma 74147, A 501(c)(3) Organization
/
Web: www.bcapfund.org, e-mail: bcapfund@bcapfund.org
A local charity serving Greater Tulsa
Authorization for the Use or Disclosure Of Protected Health Information
I, (patient name)
hereby authorize BCAP to use or disclose Protected Health
Information in the following manner:
Release to
(name of entity to receive information)
The following Protected Health Information
(Describe the information to be used or disclosed, including descriptors such as date of service, type of service, level of detail
to be released or other specific information)
The Protected Health Information is being used or disclosed for the following purpose(s):
(List specific purposes for the Protected Health Information)
This authorization is in full force and effect until (date)
or (event that relates to patient or disclosure)
at which time this authorization to use or disclose Protected
Health Information expires.
I understand that I have the right to revoke this authorization in writing by sending notification to BCAP, P.O. Box
470065, Tulsa, Oklahoma, 74147.
I understand when I revoke this authorization, it is not effective if BCAP has already relied on the authorized use or
disclose of the Protected Health Information.
I also understand Protected Health Information released prior to this authorization may be re-disclosed by the party who
received that information and may no longer be protected by federal or state law.
I understand I have the following rights:


To inspect or copy the Protected Health Information to be used or disclosed
To refuse to sign this authorization
Signature
Date
(Patient or Personal Representative)
Printed Name of Patient or Personal Representative and Description of Personal Representative’s Authority
P.O. Box 470065, Tulsa, Oklahoma 74147, A 501(c)(3) Organization