Northwestern Medical Center

https://www.northwesternmedicalcenter.org

Employee Portal
Careers
Contact us
Donate

Main Hospital: (802) 524-5911

Find a Provider: (802) 524-1280

Find a Provider Patient Portal

Our Services
Patients & Visitors
For Our Community
About NMC

Main Hospital: (802) 524-5911

Find a Provider: (802) 524-1280

Employee Portal
Careers
Contact us
Donate

×

Home » Patients & Visitors » Pay an NMC Bill » Free care & discount policy » Jim Bashaw Application

Jim Bashaw Memorial Cancer and Catastrophic Illness Fund Application

(Please note: applicant must be a resident of Franklin or Grand Isle County, VT)

Applicant Name*
First Last
Date of Birth*
MM
DD
YYYY
Gender
- Male
- Female
- Other
Who is completing this form?*
- Applicant
- Other
Permission*
I have obtained the patient's permission to apply on their behalf.
- Yes
- No
Applicant's Email
Home Phone
Work Phone
Applicant's County*
Applicant must be a resident of Franklin or Grand Isle County, VT
Applicant's Town of Residence
If different from mailing address
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Is your mailing address different than your physical address?*
- Yes
- No
Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you have health insurance?*
Check the services you use
- Medicare
- Medicaid
- Commercial Insurance
Number of adults you are financially responsible for
Number of children under 18 you are financially responsible for
Please list estimated household monthly income
Total amount requested by applicant*
Please enter a number less than or equal to 500.
Do you have an active/current cancer diagnosis?*
- Yes
- No
Select your cancer diagnosis*
Describe your catastrophic illness
Who is your treating physician?
May we contact your physician?
- Yes
- No
Explain the need for this grant*
- Please check if this is an URGENT or time-sensitive need.
Method of grant distribution*
Specify vendor mailing address & phone number; include name on account and account number*
Specify your need for an onsite distribution*
Is this a first request?
Would you be willing to share with us how this fund has helped you in the past?
- Yes
- No
Share your story
Would you like to receive future notices on fundraising opportunities for the Jim Bashaw Fund?
- Yes, please
- No, thank you
How were you made aware of this fund?
By checking this box, I affirm that all information provided in this application is accurate to the best of my knowledge. I authorize Northwestern Medical Center to verify any given information as needed to determine eligibility.*
- I agree
Please type the name of the person filling out this form, if not applicant
Contact phone number for person filling out form, if not applicant
Email address of person filling out this form, if not applicant
Documentation
Please upload receipts or invoices for reimbursement.

For more info, please call the Care Management Department at (802) 524-8479.

We will do our best to process applications quickly, especially those that are urgent, but please note that the committee may take up to 30 days.

Find a Provider Patient Portal

Patients & Visitors

Contact us: 802-524-5911

Information

Find us
Careers
Hospital report card
NMC employee policies

Services

Urgent Care
Physical Therapy
Orthopaedics
Ear Nose & Throat
See all

NMC blog

News & Updates
Ask Jill
Upcoming Events
NMC Stories
View all

Northwestern Medical Center

complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

English | Español | 繁體中文 | Tiếng Việt | 한국어 | Tagalog | Русский | العربية | Kreyòl Ayisyen | Français | Polski | Português | Italiano | Deutsch | 日本語 | فارسی | Cushite

Northwestern Medical Center
133 Fairfield Street, St. Albans, Vermont 05478

© 2019 Northwestern Medical Center all rights reserved

No thanks