ࡱ>  5@ ibjbj22 3XXNF6666+++8+D20d00a(aaadHszxzzzzzz$Rѐd~Hd^d"d~d~66aa3DJJJd~l6Ra8axJd~xJ&JpV@"a0 `G+j$ \w<0xc:c6666cd~d~Jd~d~d~d~d~ #$("# Application for Services All sections must be completed to receive full consideration  Mother s General Information Full Name:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Street Address:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       City: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       FORMTEXT       Home Phone:  FORMTEXT       FORMTEXT       FORMTEXT       Alternate Phone:  FORMTEXT       FORMTEXT       FORMTEXT       Type:  FORMCHECKBOX  cell  FORMCHECKBOX  work Email:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Age:  FORMTEXT       Date of Birth:  FORMTEXT       FORMTEXT       Diagnosed Illness:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Medical Considerations:  FORMCHECKBOX  wheelchair  FORMCHECKBOX  oxygen  FORMCHECKBOX  other  FORMTEXT       Marital Status:  FORMCHECKBOX  married  FORMCHECKBOX  single  Spouse s Information Full Name:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Street Address:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       City: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       FORMTEXT       Home Phone:  FORMTEXT       FORMTEXT       FORMTEXT       Alternate Phone:  FORMTEXT       FORMTEXT       FORMTEXT       Type:  FORMCHECKBOX  cell  FORMCHECKBOX  work Email:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Age:  FORMTEXT       Date of Birth:  FORMTEXT       FORMTEXT         Power of Attorney Do you have a Power of Attorney?  FORMCHECKBOX  yes  FORMCHECKBOX no Are they currently acting on your behalf?  FORMCHECKBOX  yes  FORMCHECKBOX no Full Name:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Street Address:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       City: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       FORMTEXT       Home Phone:  FORMTEXT       FORMTEXT       FORMTEXT       Alternate Phone:  FORMTEXT       FORMTEXT       FORMTEXT       Type:  FORMCHECKBOX  cell  FORMCHECKBOX  work Email:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Age:  FORMTEXT       Date of Birth:  FORMTEXT       FORMTEXT        Family Information Number of dependent children living with you (under the age of 18):  FORMTEXT       Total Number of children:  FORMTEXT       Names and ages of children:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        Do the listed children reside with both biological parents?  FORMCHECKBOX  yes  FORMCHECKBOX  no*  Additional Information: Please explain your children s understanding of your diagnosis.  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Please tell us why establishing your legacy is important to you.  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jh$hd>*OJQJU&jKh$hd>*OJQJU FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Please explain your prognosis as you understand it.  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        REQUIRED SIGNATURES  I understand and agree: That no promises or assurances whatsoever have been made to me by any representative of the Let There Be Mom organization regarding providing any services to me or my family; That granting services of any kind is contingent upon approval by the Let There Be Mom organization and my physician, as well as full compliance with all conditions, qualifications, and restrictions designated by the Let There Be Mom organization; That all individuals with parental or custodial rights for the children must approve participation with the Let There Be Mom organization and sign all necessary documents before services can begin; and That full disclosure of anyone having power-of-attorney over me must be made and they must complete the appropriate documents before the Let There Be Mom organization will consider offering services to me. I promise that the information provided by me is true and complete to the best of my knowledge.  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Mother s Signature Date Power of Attorney Signature Date  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Please Print Name Please Print Name  Authorization For Use/Disclosure of Protected Health Information  I authorize the use and disclosure to Let There Be Mom Inc( ( Let There Be Mom ) of protected health information about Patient, as described below. 1. Information that may be used/disclosed: All protected health information relating to Physician s assessments of whether Patient is medically eligible for Let There Be Mom s services. In addition, Physician is authorized to fill out, sign and provide to Let There Be Mom any forms that Let There Be Mom may require, including forms relating to Patient s medical eligibility, the requested services and medical considerations relating thereto. 2. Persons authorized to use/disclose the information: The Physician identified above, as well as his/her authorized representatives. 3. Persons authorized to receive the information: Employees or other authorized representatives of: Let There Be Mom Inc Phone: (864)-608-9819 Fax: (864)234-7781 4. Purpose for which information will be used/disclosed: To enable Let There Be Mom to obtain: (a) Physician s assessments regarding whether Patient is medically eligible to receive services from Let There Be Mom and, if so, whether the requested services are medically appropriate; and (b) pertinent information relating thereto. 5. Expiration date/event: This authorization expires once Patient has completed services with Let There Be Mom, or a final determination has been made that Patient is not medically eligible to receive services. 6. Statements required by HIPAA: In accordance with the Health Insurance Portability and Accountability Act, I acknowledge the following: A. I understand that I may revoke this authorization at any time by so notifying you in writing, except to the extent that action has already been taken in reliance on the authorization; B. I understand that I may refuse to sign this authorization and that my refusal to do so will not affect Patient s ability to obtain treatment or payment or eligibility for benefits; and C. I understand that if the person/entity that receives the information described above is not a healthcare provider or health plan covered by federal privacy regulations, such information will no longer be protected by these regulations and could potentially be re-disclosed by the recipient. _________________________________ _________________________________ (Patient s representative) (Signature of Patient) Date: ________________  Publicity Release Let There Be Mom would appreciate your permission to use your story and/or photo in one or more of the media listed below. Please check all the boxes that are acceptable to you. It is very helpful to Let There Be Mom to be able to share the stories of the Moms we help. Awareness of our organization is crucial to our ability to help you and other families in similar situations. Please know that Let There Be Mom does its best to honor all requests, however participation as a Let There Be Mom family may result in publicity, whether or not Let There Be Mom actively takes any steps to publicize our services to you. Let There Be Mom Applicant:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Address:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       City:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       State: FORMTEXT       FORMTEXT       Zip: FORMTEXT       FORMTEXT       Please check the box next to all media that is acceptable:  FORMCHECKBOX  Local Newspaper, Radio, TV  FORMCHECKBOX  State and National Newspaper, Radio and TV  FORMCHECKBOX  Let There Be Mom Newsletter  FORMCHECKBOX  Let There Be Mom Website  FORMCHECKBOX  Let There Be Mom Direct Mail  FORMCHECKBOX  All of the Above  FORMCHECKBOX  Please do not use my story and/or photo in any of the above media. Applicant s signature:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Date: FORMTEXT       FORMTEXT       Power of Attorney s signature:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Date: FORMTEXT       FORMTEXT        Physician s Statement Let There Be Mom Applicant:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       D.O.B.:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Address:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       City:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       State: FORMTEXT       FORMTEXT       Zip: FORMTEXT       FORMTEXT       My signature certifies that I am the treating physician of the Let There Be Mom applicant named above. The applicant is of sound mental capability to sign legal documents. I understand that to be eligible for services from the Let There Be Mom Organization the applicant must have been diagnosed with a life threatening condition as defined by me, the treating physician. I believe that if the above named patient (applicant) were to refuse medical treatment, their life expectancy would be two years or less. Physician s Signature: Physician s Name: Group Name: Address: City/State/Zip: Phone: Fax:  Application For Services All sections must be completed to receive full consideration Let There Be Mom Inc, 2007 Page  PAGE 2 of  NUMPAGES 7 Let There Be Mom Inc, 2007 Page 1 of 7 To: ( Physician ) (Physician s name and address) From: ( Patient ) (Patient s name and date of birth)  ^`blp&(<>@J۽۽ۉ}q`}L`:#jh$h>*UmHnHu&j*OJQJU jh$h>*OJQJUh\Ch5OJQJh$h>*OJQJh$hu>*OJQJ&jNh$hd>*OJQJU&jLNh$hd>*OJQJUh$hd>*OJQJ#jh$hd>*UmHnHu jh$hd>*OJQJU&jMh$hd>*OJQJUJNbdfpt  "$.2FmY&j Rh$h>*OJQJU&jQh$h>*OJQJU&jQh$h>*OJQJU&jPh$h>*OJQJU&j,Ph$h>*OJQJU#jh$h>*UmHnHu&jOh$h>*OJQJUh$h>*OJQJ jh$h>*OJQJU FHJTXlnpz~*۽۽۽۽m۽Y۽&jTh$h>*OJQJU&jdTh$h>*OJQJU&jSh$h>*OJQJU&jtSh$h>*OJQJU&jRh$h>*OJQJUh$h>*OJQJ#jh$h>*UmHnHu jh$h>*OJQJU&jRh$h>*OJQJU*,.8<PRT^bvxz۽۽۽۽m۽Y۽&jWh$h>*OJQJU&j4Wh$h>*OJQJU&jVh$h>*OJQJU&jDVh$h>*OJQJU&jUh$h>*OJQJUh$h>*OJQJ#jh$h>*UmHnHu jh$h>*OJQJU&jTUh$h>*OJQJU 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