Catastrophic Illness in Children Relief Fund Program Application

Parent/Legal Guardian Information---------------------------------------------- Top
Parent First Name:			Parent Last Name:
Spouse First Name:			Spouse Last Name:
Marital Status:			Home Phone:
Work Phone:			Mobile Phone:
Mailing Address:
City:			State:
County:			Zip Code:
E-Mail Address:			Alt E-Mail Address:

Other Information--------------------------------------------------------------- Top
Primary Language:			Other:

What is your estimated income for that same period of time? (#.## or if unknown: leave blank or enter 0.00)
Have you applied to CICRF before?	YesNo

Medical Diagnoses and Dates

Surgeries/Treatments and Dates

Is a lawsuit pending, other than collection activity, related to the expenses submitted in this application?	YesNo
Have you ever received a settlement related to your child's medical condition?	YesNo

Sources of Income	Annual Amount
(#.## or if unknown: leave blank or enter 0.00)

Gross Wages
TANF
Social Security
Pension
SSI
Unemployment/Disability/Worker's Compensation
Strike Benefits
Veteran's Benefits
Training Stipends/School Scholarships
Alimony/Child Support
Military Allotment
Regular Support from Absent Family Member
Income from Insurance/Annuity
Income from Estates/Trusts
Income from Dividends/Interest/Rents/Royalties
Other (Specify)

Total Income for 12-month period of application

Individual legally responsible for child's medical bills:

Name	Relationship to Child	Social Security Number (###-##-####)

* To include additional information, use the Account Status text field *
For 12-month period of application

Total Amount of Bill	Amount Covered by Ins. or Other Source	Amount Paid by Family	Current Balance Due	Date(s) of Service
#.##	#.##	#.##	#.##	MM/DD/YYYY

* To include additional information, use the Account Status text field *
For 12-month period of application

Total Amount of Bill	Amount Covered by Ins. or Other Source	Amount Paid by Family	Current Balance Due	Date(s) of Service
#.##	#.##	#.##	#.##	MM/DD/YYYY

* To include additional information, use the Account Status text field *
For 12-month period of application

Total Amount of Bill	Amount Covered by Ins. or Other Source	Amount Paid by Family	Current Balance Due	Date(s) of Service
#.##	#.##	#.##	#.##	MM/DD/YYYY

Parent/Guardian 1 full name:
Employer name:
Employer address:
Occupation:
Self Employed Part Time Full Time Migrant Worker Unemployed

Parent/Guardian 2 full name:
Employer name:
Employer address:
Occupation:
Self Employed Part Time Full Time Migrant Worker Unemployed

For 12-months of application unless otherwise specified
Health Insurance for child is available through:
	Employer sponsored plan	YesNo
	Small Group	YesNo
	Self Pay	YesNo
	Self-employed business	YesNo
	Non custodial parent	YesNo
	NJ Medicaid	YesNo
	Uninsured	YesNo
	COBRA	YesNo
	NJ Family Care	YesNo
Health Insurance that covers your child:
	Managed Care (HMO,PPO, POS, etc.)
	Indemnity
	Union
	Self Funded
	NJ Medicaid (NJ FamilyCare, Medicaid Waivers)
	Other
Cost of Health/Dental/Vision Insurance:
	Payroll Deduction (#.## or if unknown: leave blank or enter 0.00):
	Select:	WeeklyBiweekly
	Premium Payment (#.## or if unknown: leave blank or enter 0.00):
	Select:	MonthlyQuarterly

Expenses are a result of the following: (check all that apply)
	Co-Pays/Deductibles/Coinsurance	Exceeded Allowable Charge
	Exceeded Maximum Benefits per Lifetime	Exceeded Maximum Benefits per Year
	Excluded Services or Supply	Expenses Not Covered under Health Plan
	Insurance Denied Coverage	No Pre-Authorization/Pre-Certification
	Non-Participating Provider/Out-of-Network	Pre-Existing Condition
	Other

If you have received financial assistance from another state agency, provide the following:
Name of Agency:
Contact:
Telephone Number:
Financial Assistance Received:
If you have a loan for any of these expenses, complete the following:
Name of Lending Institution:
Address:
Telephone Number:
Loan Number:

How did you hear about the Catastrophic Illness in Children Relief Fund Program? (Check all that apply)
Newspaper/Magazine	Employer/Co-worker
Provider	TV
SCHS Case Manager	Radio
Elected Official	Friend
Bus Advertising	School Nurse
Internet/Website	Billboard
Collection Agency/Law Firm	Other

Did you file an appeal with your insurance company?
	YesNo	If Yes. the appeal is: