Patient’s Bill of Rights

Our Pledge Regarding Medical and Financial Information

Circle of Hope cares about your privacy.
The privacy of your medical information is important to Circle of Hope, Inc. We understand that your medical and financial information is personal and we are committed to protecting it. We create a record of medical and financial history to process your application and continue your financial aid, if accepted. We need these records to show we’re fair and ethical in our application process and to legally make sure you meet the criteria of our mission statement.

Our Legal Duty

The law requires us to keep your medical information private. We give you this notice describing our legal requirements regarding our privacy practices and your rights regarding your medical and application information.

Our Commitment to You

We are committed to delivering the best case management services possible. We believe that you, as a patient, have:

  • The right to be treated with respect and dignity.
  • The right to privacy and confidentiality, which includes all paperwork needed to process your application and continue your financial medical assistance, if qualified.
  • The right to know that the medical authorization is only to assist with getting information to help your financial medical aid or to assist with clarification regarding your medical bills.
  • The right to know all of your options concerning your financial medical aid and for you to be an important part of the decision making process.
  • The right to withdraw from the process at any time.
  • The right to coordinate your payment scheduling to suit your needs with the Client Coordinator, upon approval of your application.
  • The right to appeal the process in the event that you feel your rights have been violated or you have been treated improperly. You can present your appeal to the Executive Director in writing to 28042 Avenue Stanford, Suite E, Valencia, CA  91355
Circle of Hope’s Rights from the Client

Circle of Hope has the right to be told of any changes in your medical insurance, medical condition, financial status and/or Disability Insurance status. Failure to do so can result in the termination of your application process or being granted financial medical aid.

Eligibility Criteria

Clients seeking financial aid from the Circle of Hope, Inc. must have been diagnosed with breast, cervical, uterine, ovarian, testicular, prostate, colon or melanoma cancer and be currently pursuing a treatment plan. A treatment plan is defined as treatment necessary to cure or stabilize current cancer or take medication for high risk survivors prescribed by a state board-certified medical physician. We offer up to $500 for a Second Opinion and up to $12,000 for financial aid.* We do not pay for past medical bills unless stated in Past Bill Waiver.*

Clients who have completed surgery, chemotherapy, or radiation for primary cancer or recurrence and have no evidence of disease are not considered to be in treatment for active cancer thus are not eligible for aid from Circle of Hope, Inc. The only exception is for treatment with adjuvant tamoxifen or similar hormonal therapy prescribed for high risk patients for up to 10 years who have finished surgery, chemotherapy or/and radiation. These high-risk clients may obtain aid for prescription drugs to block or stop estrogen production. If you stop treatment for any reason (except due to lack of funds) against the advice of your oncologist or primary treating physician, you will no longer be eligible for financial aid.

Clients seeking aid must reside, work or receive treatment within the Santa Clarita Valley.

A client must be a US Citizen or permanent legal resident. Financial aid will be on a first come, first serve basis as funds are available; and are for new medical expenses (co-pays, deductibles, medicine, COBRA & insurance premiums, second opinion, etc.) Circle of Hope funds will be utilized as a last resort.

All forms must be completed and received before a determination is made. Those forms are:

  • Client Application for Financial Aid or Second Opinion Assistance
  • Authorization
  • Medical Release(s) (not needed for Second Opinion Assistance)
  • Proof of income

Final determination of qualification for aid is at the discretion of the Circle of Hope Board of Directors.

*Past Bill Waiver:

Past medical bills up to $12,000 will be considered if:

  1. You qualify for client status
  2. Medical bills are accrued during treatment for breast cancer are not past due more than 365 days
  3. Bills have been negotiated to their lowest amount
  4. Medical bills are paid for “treatment” only. “Treatment” begins with lumpectomy/mastectomy (or other surgery), chemotherapy and/or radiation. It does not include diagnostic procedures, such as mammograms, needle biopsy, scans, etc .to determine “if” you have  cancer. Full pathology report is needed. This report is given upon surgery that describes the type of cancer & staging that is used for determining one’s cancer treatment. 
  5. Consolidated debt is a one-time offer

Past bills are part of the life-time $12,000 allotment for financial aid. Circle of Hope maintains discretion regarding which past due bills will be paid with an emphasis on bills which must be paid to insure future treatment, follow-up testing and medical insurance. Financial aid is best asked for at the time of diagnosis. Costs are an accumulation of surgery, hospitalization, chemotherapy, radiation, medications & labs prescribed by oncologist/radiologist, additional testing after pathology report, reconstruction and doctor visits, that make up one’s total treatment package of being treated for cancer. Consider you may have a deductible payment to make, co-payments, or insurance premiums to be paid before anything is “allotted paid” by your insurance.

 Application Packet Procedures

  1. Fill out and complete Financial Aid OR Medical Second Opinion Application
    a. Must be completed and signed by client or client’s appointed representative
    b. Must provide current photo ID
    c. Must provide proof of U. S. Citizenship (by birth certificate or passport) or a copy of your permanent legal residency
    d. Copy of proof of income: household’s last three month’s pay stubs, public assistance, most recent year’s income tax returns, last (3) months bank statements (Not required for Second Opinion application)
    e. *Must provide copies of medical bills and pathology report accrued during treatment if asking for Past Bill Waiver to be considered. Please note: all medical bills must be accompanied with an (EOB) Explanation of Benefits provided by your insurance company.
    f. Copy of Insurance Card front and back
  2. Fill out Medical Release, Authorization for Disclosure of Individual Health Information form
    a. Signed Medical Release(s). Client signature is required before any assistance may be granted. Note: The purpose of this information is to obtain verification of diagnosis/treatment.
  3. Interview with a Circle of Hope, Inc. representative for clarification purposes and presentation of documents will be necessary
    a. Phone number(s) where we may reach you is required
  4. Send application to: Circle of Hope, Inc., 28042 Avenue Stanford, Suite E, Valencia, CA  91355, or fax information to our office at (661) 254-5255.
    a. Signed & completed application
    b. Current photo ID and proof of citizenship or legal residency
    c. Proof of income and/or government aid program you’re in (Ex. SSD; SSI, Disability, etc.)
    d. Tax Return and last (3) months bank statements
    e. Signed Medical Release form(s)
    f. Copy of Insurance Card
    g. (EOB) Explanation of Benefits
  5. Notification: Upon completion of Application and board voting, a letter will be mailed stating your Approval Status.
Support for this program is based on the availability of funds. Circle of Hope reserves the right to adjust or change criteria without notification.

 Apply Now


Additional Forms

3 Comments on “Apply for Help”

  1. Sherrie Bagaus

    My daughter lives in Canyon Country and is having a mastectomy on Wed., July 8th.at Holy Cross.

    I am confused about your program. Does she apply for financial assistance by tomorrow? I just found your website. Or does she wait until after the surgery and receives her first bill to apply?

    I could not find the financial form you requested to be completed.

    Your website states when funds are available. Are there any funds left for 2015?

    If no fund are available, are you aware of any other financial assistance programs to help with hospital bills?

    She has insurance, but is unaware of the cost of the surgery, ect., her doctor told her not to worry. She is unaware of the amount her insurance will cover after her deductible, and the balance she will be responsible for.

    I look forward to hearing from you soon.

    Sincerely,
    Sherrie Bagaus (concerned Mom)

    1. Circle of Hope

      Hello Sherrie,

      Thank you for contacting us about assistance. I am forwarding your questions to our Executive Director, Ray Tippet. You can expect to hear from him with more detailed answers than I can offer. I’ll have him email you at the gmail address you provided. In the meantime, if you wish to fill out the application, you may find it at this link https://circleofhopeinc.org/financial-aid-application/

      We hope all went well with your daughter’s procedure today, and look forward to assisting you.

      Thank you,
      Angela (Webmaster)

  2. Sylvia Ferrara

    Ray, I am asking the same question as the previous request as to if the application is submitted before or after the surgery, after I’m billed.

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