2024 Patient Registration Form

*PLEASE ENTER YOUR INFORMATION BELOW. WE WILL EMAIL A FINAL APPLICATION FOR SIGNATURE.

The final application must be completed and signed by the Patient (or their representative) and their Doctor, Nurse or Social Worker. Final submission requires three attachments a) signed patient registration, b) signed medical information, c) letter with details on hospital letterhead, plus all applicable receipts.

GENERAL GUIDELINES

To be eligible for the program, the following criteria must be met and (3) attachments submitted (+ applicable receipts):

• Patient must be a candidate for a bone marrow or cord blood transplant, receiving medical treatment at a certified medical center in the United States.
• Patient must have a household income that is at or below 400% of the current U.S. Federal Poverty Guidelines to be considered for financial support.
• Patient must be in active treatment with a scheduled date to receive a bone marrow transplant (or within 60 days post-transplant).
• Submit attachment a) PATIENT REGISTRATION, completed and signed by patient or family member.
• Submit attachment b) MEDICAL INFORMATION, completed by a Social Worker, Nurse or Doctor at the medical center.
• Submit attachment c) letter using hospital letterhead verifying diagnosis, need for a transplant, and details regarding the financial support requested (use of funds, timing, amount).

USE OF FUNDS

The maximum allowance per patient is $500, The IclaCares Critical Fund may be requested by patients and their families to cover costs associated with the following:

• Lodging while in treatment
• Transportation to receive treatment (including Gas/Parking/Taxi/Flight)
• Meal assistance during treatment (Groceries)
• HLA Compatibility testing (we utilize Labcorp for testing)
• Other (pending need and approval)

*The Icla da Silva Foundation reserves the right to deviate from these Guidelines when special circumstances arise on a case-by-case basis. Priority for grants is given to patients demonstrating the greatest financial need.

DISBURSEMENT OF FUNDS

Funds are dispersed directly to a specific vendor. Receipts or a bill must accompany all expense requests. There are some circumstances when funds may be provided to patients directly.

Enter Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Patient Email Address (DO NOT ENTER SOCIAL WORKER EMAIL) *

Patient Cell Phone *

Address 1 *

City *

State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code *

Patient Diagnosis Acute Biphenotypic Leukemia (ABL) Acute Lymphocytic Leukemia (ALL) Acute Myeloid Leukemia (AML) Acute Promyelocytic Leukemia (APL) Acute Undifferentiated Leukemia (AUL) Adrenoleucodistrophy Amyloidosis Anaplastic Large Cell Lymphoma (ALCL) Aplastic Anemia Beta Thalassemia Blastic Plasmacytoid Dendritic Cell Neoplasm Burkitts Lymphoma Chronic Granulomatous Disease Chronic Lymphocytic Leukemia (CLL) Chronic Myelogenous Leukemia (CML) Chronic Myelomonocytic Leukemia (CMML) Diffused Large B-cell Lymphoma Dyskeratosis Gongenita EBV Induced Lymphoproliferative Disease Fanconi Anemia FLH/HLH Follicular Lymphoma Germ Cell Tumor Hodgkin's Lymphoma Hurler Syndrome (MPS I) Hyper Eosiniphilic Syndrome I-Pex Juvenile Myelomonocytic Leukemia (JMML) Krabbe Langerhans Cell Histiocytosis (LCH) Leucodistrophy Light Chain (AL) Amyloidosis Lorezon’s Oil Disease Lupus Malignant Infantile Osteopetrosis (MIOP) Mantle Cell Lymphoma Medulloblastoma (Brain Tumor) Megaloblastic Anemia Multiple Myeloma Myelodysplastic Syndromes (MDS) Myelofibrosis Myeloproliferative Disorders (MPD) Neuroblastoma Non-Hodgkin's Lymphoma Other Paroxysmal Nocturnal Hemoglobinuria POEMS Syndrome Pre B cell Acute Lymphoblastic Leukemia Primary Central Nervous System Lymphoma Refractory Cytopenia of Childhood Severe Combined immunodeficiency (SCID) Severe Congenital Neutropenia Sickle Cell Anemia T-Cell Lymphoma Thrombocytopenia Unclassified Wiskott Aldrich Syndrome (WAS)

Patient Hospital *

Parent/Legal Guardian Name

Relationship to Patient (Parent/Spouse/Sibling/Caregiver)

Lead Family/Contact Phone Number

Lead Family Contact Email

Social Worker Name *

Social Worker Email *

Social Worker Phone # *

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