Para ver la solicitud en otro idioma, haga clic en el botón en la esquina superior derecha de la pantalla (el símbolo del globo) que dice "English". A continuación, seleccione su idioma preferido de los cuadros de selección, que se muestran a continuación. Estas opciones aparecerán en la parte superior izquierda de la pantalla debajo de las palabras "Catastrophic Illness in Children Relief Fund (CICRF) Application". La encuesta se traducirá al idioma seleccionado.
To view the application in another language, click the button in the top right corner of your screen (the globe symbol) that says "English". Next, select your preferred language from the selection boxes, pictured below. These options will show up at the top left of your screen underneath the words "Catastrophic Illness in Children Relief Fund (CICRF) Application". The survey will then be translated into the language you selected.
English Spanish
CICRF is a program of the Massachusetts Department of Public Health's (MDPH) Bureau of Family Health and Nutrition (BFHN) and sits within the Division for Children & Youth with Special Health Needs (DCYSHN). For more information about CICRF, please visit our website at https://www.mass.gov/cicrf. To learn more about the wide range of programs offered by BFHN and DCYSHN, visit www.mass.gov/dph/specialhealthneeds.
Who is eligible?
CICRF provides reimbursement for eligible medically related expenses for families of children and young adults with significant medical needs who meet the following:
Families with eligible expenses greater than 10% of the first $100,000 of annual family income from all sources plus 15% of any family income over $100,000 Child/youth under age 22 at time of the expense Massachusetts residents
The Application
The application will ask you to enter information such as
You and your child's name, address, contact information, preferred language, date of birth, health insurance, your child's diagnosis, and demographics (your child's race and ethnicity). Hospitals your child has used, your income and your expenses. You will be asked to upload proof of your income (tax return, Social Security benefit letter, etc.) and expenses (invoices, payment receipts, etc.) Read and sign a consent form You must enter all required information before submitting the application. However, the application is designed so you do not have to complete it all at one time.
To save your application click on the "Save & Return Later" button at the bottom of the screen. You will be sent to a page titled "Your survey responses were saved!" and will have to enter your email address. You will then receive an email from dphredcap@massmail.state.ma.us with the subject line "Survey partially completed." In the email, there will be a link to your saved application.
To return to your application, click on the link in the email. You must enter your child's first name, date of birth, and their zip code to be brought to your application. Once all information has been entered and documents have been uploaded, you can then hit the "Submit" button.
Questions or Need Help?
CICRF.DPH@mass.gov
Please contact CICRF by phone or email in your preferred language and leave your phone number and the best times to call. We will reply within 1-2 days, with an interpreter if needed.
APPLICANT & FAMILY INFORMATION Child/Youth * Must be under age 22 at time of expense *
Legal Name (First)
Names (All Last)
Date of Birth:
Street Address
City
State
Zip Code
What is your child's gender identity? Check all that apply regardless of sex assigned at birth.
Child's Name (First) / (Primer) Nombre del niño/a/joven
* must provide value
Child's Name (Last)
* must provide value
Child's Street Address
* must provide value
Child's City
* must provide value
Child's State
* must provide value
MA Other state, specify
Child's State - Other
* must provide value
Child's Zip Code / Código Postal de la dirección
* must provide value
Child's Date of Birth / Fecha de Nacimiento
* must provide value
Today M-D-Y
The option "
Child's gender identity
* must provide value
Parent/Guardian #1 Legal Name (First): Names (All Last): Relationship to Child:
Contact Information Home Phone:
Cell Phone:
E-mail:
Please select contact preference:
In what language do you prefer to communicate?
In what language do you prefer to receive written materials?
Address Is the home address the same as the child's?
Is the mailing address the same as the home address?
Additional parent/caregiver Do you want to add another parent/guardian to the application?
Guardian #1 Name (First)
* must provide value
Guardian #1 Name (Last)
* must provide value
Guardian #1 Relationship to Child
* must provide value
Mother Father Legal guardian Other - please specify
Guardian #1 Other relationship, specify:
* must provide value
Guardian #1 E-mail
* must provide value
Guardian #1 Contact preference:
* must provide value
Home phone
Cell phone
Text message
Parent/Guardian #1: Home Address Line 1: Line 2: City: State:
Zip Code:
Guardian #1: Is the home address the same as the child's?
* must provide value
Yes
No, please enter address below
Guardian #1 Home Address (Line 1)
* must provide value
Guardian #1 Home Address (Line 2)
Guardian #1 Home Address (City)
* must provide value
Guardian #1 Home Address (State)
* must provide value
MA Other state, specify
Guardian #1 State Other
* must provide value
Guardian #1 Home Address (Zip Code)
* must provide value
Parent/Guardian #1: Mailing Address (if different from home address) Line 1:
Line 2:
City: State:
Zip Code:
Guardian #1: Is the mailing address the same as the home address?
* must provide value
Yes
No, please enter address below
Guardian #1 Mailing Address (Line 1)
* must provide value
Guardian #1 Mailing Address (Line 2)
Guardian #1 Mailing Address (City)
* must provide value
Guardian #1 Mailing Address (State)
* must provide value
MA Other state, specify
Guardian #1 Mailing Address (State Other)
* must provide value
Guardian #1 Mailing Address (Zip Code)
* must provide value
Do you want to add another parent/guardian?
* must provide value
Yes No
Parent/Guardian #2 Legal Name (First): Names (All Last): Relationship to Child:
Contact Information Home Phone:
Cell Phone:
E-mail:
Please select contact preference:
In what language do you prefer to communicate?
In what language do you prefer to receive written materials?
Address
Is the home address the same as the child's?
Is the mailing address the same as the home address?
Guardian #2 Name (First)
* must provide value
Guardian #2 Name (Last)
* must provide value
Guardian #2 Relationship to Child
* must provide value
Mother Father Legal guardian Other - please specify
Guardian #2 Other relationship, specify:
* must provide value
Guardian #2 E-mail
* must provide value
Guardian #2 Please select contact preference:
* must provide value
Home phone
Cell phone
Text message
Parent/Guardian #2: Home Address Line 1: Line 2: City: State:
Zip Code:
Guardian #2: Is the home address the same as the child's?
* must provide value
Yes
No, please enter address below
Guardian #2 Home Address (Line 1)
* must provide value
Guardian #2 Home Address (Line 2)
Guardian #2 Home Address (City)
* must provide value
Guardian #2 Home Address (State)
* must provide value
MA Other state, specify
Guardian #2 Home Address (State Other)
* must provide value
Guardian #2 Home Address (Zip Code)
* must provide value
Parent/Guardian #2: Mailing Address (if different from home address) Line 1: Line 2:
City: State:
Zip Code:
Guardian #2: Is the mailing address the same as the home address?
* must provide value
Yes
No, please enter address below
Guardian #2 Mailing Address (Line 1)
Guardian #2 Mailing Address (Line 2)
Guardian #2 Mailing Address (City)
* must provide value
Guardian #2 Mailing Address (State)
* must provide value
MA Other state, specify
Guardian #2 Mailing Address (State Other)
* must provide value
Guardian #2 Mailing Address (Zip Code)
* must provide value
Guardian #1: In what language do you prefer to communicate?
* must provide value
Albanian American Sign Language Amharic, Somali, or other Afro-Asiatic Arabic Armenian Cape Verdean Creole Chinese (please specify dialect below) English Farsi French German Greek Haitian Creole Hindi Hmong Italian Khmer Korean Polish Portuguese Russian Spanish Swahili or other Eastern or Southern African Tagalog Thai Urdu Vietnamese Yoruba, Twi, Igbo, or other Western African Other (please specify below) Prefer not to answer
Guardian #1: Please specify other spoken language:
* must provide value
Guardian #1: In what language do you prefer to receive written materials?
* must provide value
Albanian Amharic, Somali, or other Afro-Asiatic Arabic Armenian Cape Verdean Creole Chinese (Simplified) Chinese (Traditional) English Farsi French German Greek Haitian Creole Hindi Hmong Italian Khmer Korean Polish Portuguese Russian Spanish Swahili or other Eastern or Southern African Tagalog Thai Urdu Vietnamese Yoruba, Twi, Igbo, or other Western African Other (please specify below) Prefer not to answer
Guardian #1: Please specify other written language:
* must provide value
Guardian #2: In what language do you prefer to communicate?
* must provide value
Albanian American Sign Language Amharic, Somali, or other Afro-Asiatic Arabic Armenian Cape Verdean Creole Chinese (please specify dialect below) English Farsi French German Greek Haitian Creole Hindi Hmong Italian Khmer Korean Polish Portuguese Russian Spanish Swahili or other Eastern or Southern African Tagalog Thai Urdu Vietnamese Yoruba, Twi, Igbo, or other Western African Other (please specify below) Prefer not to answer
Guardian #2 Please specify other spoken language:
* must provide value
Guardian #2: In what language do you prefer to receive written materials?
* must provide value
Albanian Amharic, Somali, or other Afro-Asiatic Arabic Armenian Cape Verdean Creole Chinese (Simplified) Chinese (Traditional) English Farsi French German Greek Haitian Creole Hindi Hmong Italian Khmer Korean Polish Portuguese Russian Spanish Swahili or other Eastern or Southern African Tagalog Thai Urdu Vietnamese Yoruba, Twi, Igbo, or other Western African Other (please specify below) Prefer not to answer
Guardian #2: Please specify other written language:
* must provide value
The option "
How did you learn about CICRF? Please select all that apply.
* must provide value
Please specify other referral source:
* must provide value
CHILD/YOUTH'S HEALTHCARE INFORMATION This section asks you questions about your child's health insurance, whether they have a primary care doctor and asks you about your child's diagnosis and how it may impact you and your family.
What kind of health insurance does your child have? Please indicate your child's primary health insurance.
* must provide value
Private Health Insurance, please specify policy holder
Medicaid or MassHealth, specify type
Children Medical Security Plan (CMSP)
TRICARE or other military healthcare, please specify policy holder
Other health insurance, please specify
No insurance
Don't know
Declined to answer
Policy Holder Name (Private Insurance)
* must provide value
Type of Medicaid or MassHealth
* must provide value
CommonHealth Kaileigh Mulligan MassHealth Family Assistance MassHealth Limited MassHealth Standard
Policy Holder Name (TRICARE):
* must provide value
Please specify plan (other insurance):
* must provide value
Does your child have a secondary health insurance?
* must provide value
Yes No Don't know Decline to answer
Please indicate your child's secondary health insurance.
* must provide value
Private Health Insurance, please specify policy holder
Medicaid or MassHealth, specify type
Children Medical Security Plan (CMSP)
TRICARE or other military healthcare, please specify policy holder
Other health insurance, please specify
No insurance
Don't know
Declined to answer
Secondary Insurance Policy Holder Name (Private Insurance):
* must provide value
Type of Medicaid or MassHealth (Secondary)
* must provide value
CommonHealth Kaileigh Mulligan MassHealth Family Assistance MassHealth Limited MassHealth Standard
Secondary Insurance Policy Holder Name (TRICARE):
* must provide value
Please specify plan (other secondary insurance):
* must provide value
Does your child have a pediatrician or primary care doctor?
* must provide value
Yes No Don't know Declined to answer
The option "
What are your child's primary diagnoses? Please select all that apply. You can also write in their diagnoses if you do not see it.
* must provide value
Type of cancer
* must provide value
Please specify your child's cardiac condition(s):
* must provide value
Other cardiac condition
* must provide value
Please specify your child's chromosomal or genetic disorder(s):
* must provide value
Other genetic condition
* must provide value
Please specify your child's chronic feeding issue(s):
* must provide value
Other feeding issues
* must provide value
Please specify your child's chronic lung disease:
* must provide value
Other lung disease
* must provide value
Please specify your child's congenital brain abnormalities or neurological disorder(s):
* must provide value
Other neurological disorder
* must provide value
Type of developmental delay
* must provide value
Type of hearing loss
* must provide value
Type of intellectual disability
* must provide value
Type of leukodystrophy
* must provide value
Please specify your child's metabolic disorder(s):
* must provide value
Other metabolic disorder
* must provide value
Please specify your child's orthopedic diagnosis:
* must provide value
Other orthopedic diagnosis
* must provide value
Please specify your child's visual impairment(s):
* must provide value
Other visual impairment
* must provide value
Please specify other birth defects:
* must provide value
Other birth defect
* must provide value
Other diagnosis
* must provide value
Does your child have a physical, mental, or developmental condition that is expected to last at least one year?
* must provide value
Yes No Don't know Decline to answer
Does this condition cause weakness, severe pain, nausea, reduce their strength and abilities, and/or limit major life activities?
* must provide value
Yes No Don't know Decline to answer
Does this condition involve 2 or more body systems? Body systems are groups of organs and tissues that work together to perform important jobs for the body such as the heart, lungs, muscles, digestive system, nervous system or immune system.
* must provide value
Yes No Don't know Decline to answer
Does your child have a condition that does not have a current cure and is expected to shorten their life?
* must provide value
Yes No Don't know Decline to answer
Does your child have, or do you expect your child to have an ongoing need for technology for at least 6 months (for example, a feeding tube, oxygen, or ventilator)?
* must provide value
Yes No Don't know Decline to answer
Does your child currently have cancer or had cancer within the last 5 years?
* must provide value
Yes No Don't know Decline to answer
Is your child limited or prevented in any way in their ability to do the things most children of the same age can do?
* must provide value
Yes, mildly limits their daily activities Yes, moderately limits their daily activities Yes, severely limits their daily activities No Don't know Decline to answer
The option "
Within the last 2 years, has your child had any of the following?
* must provide value
The option "
Are the health needs of your child posing a significant impact on your family with regards to the following? Check all that apply.
* must provide value
CHILD/YOUTH'S HEALTHCARE USAGE This section asks you about any hospitals your child may have used within the past 24 months.
Has your child used any hospitals in the past 24 months (include inpatient and outpatient care)? If yes, please list up to 6 hospitals below.
Yes No Don't know Decline to answer
Hospital 1: Hospital 2: Hospital 3: Hospital 4: Hospital 5: Hospital 6:
Anna Jacques Hospital Baystate Franklin Medical Center Baystate Medical Center Baystate Noble Hospital Baystate Wing Hospital Berkshire Medical Center Beth Israel Deaconess Medical Center - Boston Beth Israel Deaconess Medical Center - Plymouth Beverly Hospital Boston Children's Hospital Boston Medical Center Brigham and Women's Hospital Brockton Hospital Cambridge Health Alliance Cape Cod Hospital Charlton Hospital Connecticut Children's Medical Center Cooley Dickinson Hospital Dana-Farber Cancer Institute Emerson Hospital Falmouth Hospital Faulkner Hospital Franciscan Children's Good Samaritan Medical Center Harrington Hospital Hasbro Children's Hospital Heywood Hospital Holy Family Hospital Holyoke Medical Center Lahey Clinic Lawrence General Hospital Leominster Hospital Lowell General Hospital Marlborough Hospital Martha's Vineyard Hospital Massachusetts General Hospital Mass Eye & Ear Infirmary McLean Hospital Melrose-Wakefield Hospital Mercy Medical Center MetroWest Medical Center Milford Regional Medical Center Morton Hospital Mount Auburn Hospital Nantucket Cottage Hospital Nashoba Valley Medical Center Newton-Wellesley Hospital Norwood Hospital Saint Anne's Hospital Saint Vincent Hospital Salem Hospital Shriner's Hospital - Boston Shriner's Hospital - Springfield South Shore Hospital Spaulding Rehabilitation Hospital St. Elizabeth's Medical Center St. Luke's Hospital Sturdy Memorial Hospital Tobey Hospital Tufts Medical Center UMass Memorial Medical Center Winchester Hospital Women's & Infant's Hospital Other, please specify
Anna Jacques Hospital Baystate Franklin Medical Center Baystate Medical Center Baystate Noble Hospital Baystate Wing Hospital Berkshire Medical Center Beth Israel Deaconess Medical Center - Boston Beth Israel Deaconess Medical Center - Plymouth Beverly Hospital Boston Children's Hospital Boston Medical Center Brigham and Women's Hospital Brockton Hospital Cambridge Health Alliance Cape Cod Hospital Charlton Hospital Connecticut Children's Medical Center Cooley Dickinson Hospital Dana-Farber Cancer Institute Emerson Hospital Falmouth Hospital Faulkner Hospital Franciscan Children's Good Samaritan Medical Center Harrington Hospital Hasbro Children's Hospital Heywood Hospital Holy Family Hospital Holyoke Medical Center Lahey Clinic Lawrence General Hospital Leominster Hospital Lowell General Hospital Marlborough Hospital Martha's Vineyard Hospital Massachusetts General Hospital Mass Eye & Ear Infirmary McLean Hospital Melrose-Wakefield Hospital Mercy Medical Center MetroWest Medical Center Milford Regional Medical Center Morton Hospital Mount Auburn Hospital Nantucket Cottage Hospital Nashoba Valley Medical Center Newton-Wellesley Hospital Norwood Hospital Saint Anne's Hospital Saint Vincent Hospital Salem Hospital Shriner's Hospital - Boston Shriner's Hospital - Springfield South Shore Hospital Spaulding Rehabilitation Hospital St. Elizabeth's Medical Center St. Luke's Hospital Sturdy Memorial Hospital Tobey Hospital Tufts Medical Center UMass Memorial Medical Center Winchester Hospital Women's & Infant's Hospital Other, please specify
Anna Jacques Hospital Baystate Franklin Medical Center Baystate Medical Center Baystate Noble Hospital Baystate Wing Hospital Berkshire Medical Center Beth Israel Deaconess Medical Center - Boston Beth Israel Deaconess Medical Center - Plymouth Beverly Hospital Boston Children's Hospital Boston Medical Center Brigham and Women's Hospital Brockton Hospital Cambridge Health Alliance Cape Cod Hospital Charlton Hospital Connecticut Children's Medical Center Cooley Dickinson Hospital Dana-Farber Cancer Institute Emerson Hospital Falmouth Hospital Faulkner Hospital Franciscan Children's Good Samaritan Medical Center Harrington Hospital Hasbro Children's Hospital Heywood Hospital Holy Family Hospital Holyoke Medical Center Lahey Clinic Lawrence General Hospital Leominster Hospital Lowell General Hospital Marlborough Hospital Martha's Vineyard Hospital Massachusetts General Hospital Mass Eye & Ear Infirmary McLean Hospital Melrose-Wakefield Hospital Mercy Medical Center MetroWest Medical Center Milford Regional Medical Center Morton Hospital Mount Auburn Hospital Nantucket Cottage Hospital Nashoba Valley Medical Center Newton-Wellesley Hospital Norwood Hospital Saint Anne's Hospital Saint Vincent Hospital Salem Hospital Shriner's Hospital - Boston Shriner's Hospital - Springfield South Shore Hospital Spaulding Rehabilitation Hospital St. Elizabeth's Medical Center St. Luke's Hospital Sturdy Memorial Hospital Tobey Hospital Tufts Medical Center UMass Memorial Medical Center Winchester Hospital Women's & Infant's Hospital Other, please specify
Anna Jacques Hospital Baystate Franklin Medical Center Baystate Medical Center Baystate Noble Hospital Baystate Wing Hospital Berkshire Medical Center Beth Israel Deaconess Medical Center - Boston Beth Israel Deaconess Medical Center - Plymouth Beverly Hospital Boston Children's Hospital Boston Medical Center Brigham and Women's Hospital Brockton Hospital Cambridge Health Alliance Cape Cod Hospital Charlton Hospital Connecticut Children's Medical Center Cooley Dickinson Hospital Dana-Farber Cancer Institute Emerson Hospital Falmouth Hospital Faulkner Hospital Franciscan Children's Good Samaritan Medical Center Harrington Hospital Hasbro Children's Hospital Heywood Hospital Holy Family Hospital Holyoke Medical Center Lahey Clinic Lawrence General Hospital Leominster Hospital Lowell General Hospital Marlborough Hospital Martha's Vineyard Hospital Massachusetts General Hospital Mass Eye & Ear Infirmary McLean Hospital Melrose-Wakefield Hospital Mercy Medical Center MetroWest Medical Center Milford Regional Medical Center Morton Hospital Mount Auburn Hospital Nantucket Cottage Hospital Nashoba Valley Medical Center Newton-Wellesley Hospital Norwood Hospital Saint Anne's Hospital Saint Vincent Hospital Salem Hospital Shriner's Hospital - Boston Shriner's Hospital - Springfield South Shore Hospital Spaulding Rehabilitation Hospital St. Elizabeth's Medical Center St. Luke's Hospital Sturdy Memorial Hospital Tobey Hospital Tufts Medical Center UMass Memorial Medical Center Winchester Hospital Women's & Infant's Hospital Other, please specify
Anna Jacques Hospital Baystate Franklin Medical Center Baystate Medical Center Baystate Noble Hospital Baystate Wing Hospital Berkshire Medical Center Beth Israel Deaconess Medical Center - Boston Beth Israel Deaconess Medical Center - Plymouth Beverly Hospital Boston Children's Hospital Boston Medical Center Brigham and Women's Hospital Brockton Hospital Cambridge Health Alliance Cape Cod Hospital Charlton Hospital Connecticut Children's Medical Center Cooley Dickinson Hospital Dana-Farber Cancer Institute Emerson Hospital Falmouth Hospital Faulkner Hospital Franciscan Children's Good Samaritan Medical Center Harrington Hospital Hasbro Children's Hospital Heywood Hospital Holy Family Hospital Holyoke Medical Center Lahey Clinic Lawrence General Hospital Leominster Hospital Lowell General Hospital Marlborough Hospital Martha's Vineyard Hospital Massachusetts General Hospital Mass Eye & Ear Infirmary McLean Hospital Melrose-Wakefield Hospital Mercy Medical Center MetroWest Medical Center Milford Regional Medical Center Morton Hospital Mount Auburn Hospital Nantucket Cottage Hospital Nashoba Valley Medical Center Newton-Wellesley Hospital Norwood Hospital Saint Anne's Hospital Saint Vincent Hospital Salem Hospital Shriner's Hospital - Boston Shriner's Hospital - Springfield South Shore Hospital Spaulding Rehabilitation Hospital St. Elizabeth's Medical Center St. Luke's Hospital Sturdy Memorial Hospital Tobey Hospital Tufts Medical Center UMass Memorial Medical Center Winchester Hospital Women's & Infant's Hospital Other, please specify
Anna Jacques Hospital Baystate Franklin Medical Center Baystate Medical Center Baystate Noble Hospital Baystate Wing Hospital Berkshire Medical Center Beth Israel Deaconess Medical Center - Boston Beth Israel Deaconess Medical Center - Plymouth Beverly Hospital Boston Children's Hospital Boston Medical Center Brigham and Women's Hospital Brockton Hospital Cambridge Health Alliance Cape Cod Hospital Charlton Hospital Connecticut Children's Medical Center Cooley Dickinson Hospital Dana-Farber Cancer Institute Emerson Hospital Falmouth Hospital Faulkner Hospital Franciscan Children's Good Samaritan Medical Center Harrington Hospital Hasbro Children's Hospital Heywood Hospital Holy Family Hospital Holyoke Medical Center Lahey Clinic Lawrence General Hospital Leominster Hospital Lowell General Hospital Marlborough Hospital Martha's Vineyard Hospital Massachusetts General Hospital Mass Eye & Ear Infirmary McLean Hospital Melrose-Wakefield Hospital Mercy Medical Center MetroWest Medical Center Milford Regional Medical Center Morton Hospital Mount Auburn Hospital Nantucket Cottage Hospital Nashoba Valley Medical Center Newton-Wellesley Hospital Norwood Hospital Saint Anne's Hospital Saint Vincent Hospital Salem Hospital Shriner's Hospital - Boston Shriner's Hospital - Springfield South Shore Hospital Spaulding Rehabilitation Hospital St. Elizabeth's Medical Center St. Luke's Hospital Sturdy Memorial Hospital Tobey Hospital Tufts Medical Center UMass Memorial Medical Center Winchester Hospital Women's & Infant's Hospital Other, please specify
Please specify the hospital your child used. A release form will be provided by CICRF and does not need to be downloaded or uploaded at this time. Please disregard the below message unless you have selected another hospital.
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Anna Jacques Hospital
Anna Jacques Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Baystate Franklin Medical Center
Baystate Franklin Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Baystate Medical Center
Baystate Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Baystate Noble Hospital
Baystate Noble Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Baystate Wing Hospital
Baystate Wing Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Berkshire Medical Center
Berkshire Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Beth Israel Deaconess Hospital - Boston
Beth Israel Deaconess Hospital (Boston) Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Beth Israel Deaconess Hospital - Plymouth
Beth Israel Deaconess Hospital (Plymouth) Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Beverly Hospital
Beverly Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Boston Children's Hospital
Boston Children's Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Boston Medical Center
Boston Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Brigham & Women's Hospital
Brigham & Women's Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Brockton Hospital
Brockton Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Cambridge Health Alliance
Cambridge Health Alliance Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Cape Cod Hospital
Cape Cod Healthcare Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Charlton Hospital
Charlton Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Connecticut Children's Medical Center
Connecticut Children's Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Cooley Dickinson Hospital
Cooley Dickinson Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Dana Farber Cancer Institute
Dana Farber Cancer Institute Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Emerson Hospital
Emerson Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Falmouth Hospital
Falmouth Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Faulkner Hospital
Faulkner Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Franciscan Children's
Franciscan Children's Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Good Samaritan Medical Center
Good Samaritan Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Harrington Hospital
Harrington Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Hasbro Children's Hospital
Hasbro Children's Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Heywood Hospital
Heywood Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Holy Family Hospital
Holy Family Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Holyoke Medical Center
Holyoke Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Lahey Clinic
Lahey Clinic Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Lawrence General Hospital
Lawrence General Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Leominster Hospital
Leominster Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Lowell General Hospital
Lowell General Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Marlborough Hospital
Marlborough Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Martha's Vineyard Hospital
Martha's Vineyard Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Massachusetts General Hospital
Massachusetts General Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Mass Eye & Ear Infirmary
Mass Eye & Ear Infirmary Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: McLean Hospital
McLean Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Melrose-Wakefield Hospital
Melrose-Wakefield Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Mercy Medical Center
Mercy Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: MetroWest Medical Center
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Milford Regional Medical Center
Milford Regional Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Morton Hospital
Morton Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Mount Auburn Hospital
Mount Auburn Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Nantucket Cottage Hospital
Nantucket Cottage Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Nashoba Valley Medical Center
Nashoba Valley Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Newton-Wellesley Hospital
Newton-Wellesley Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Norwood Hospital
Norwood Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Saint Anne's Hospital
Saint Anne's Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Saint Vincent Hospital
Saint Vincent Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Salem Hospital
Salem Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Shriner's Hospital - Boston
Shriner's Hospital - Boston Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: South Shore Hospital
South Shore Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Spaulding Rehabilitation Hosptital
Spaulding Rehabilitation Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: St. Elizabeth's Medical Center
St. Elizabeth's Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: St. Luke's Hospital
St. Luke's Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Sturdy Memorial Hospital
Sturdy Memorial Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Tobey Hospital
Tobey Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Tufts Medical Center
Tufts Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: UMass Memorial Medical Center
UMass Memorial Medical Center Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Winchester Hospital
Winchester Hospital Release Form
Hospital Name: Hospital release form to download and fill: Upload complete hospital release form here: Women & Infant's Hospital
Women & Infant's Hospital Release Form
Please list any case managers, social workers, care coordinators or others helping your family.
Name Facility/Address Phone Email Caseworker 1: Caseworker 2: Caseworker 3:
ELIGIBILITY CRITERIA AND EXPENSES
For CICRF, "catastrophic illness" refers to the amount of uncovered expenses compared to your family's annual income in a 12 month period, not the severity of your child's illness or condition.
Eligible expenses must meet or exceed the first 10% of income under $100,000 plus 15% of any income over $150,000. Please see examples below.
If your family's total income was: Medical expenses must be:
$50,000 $5,000 $100,000 $10,000 $150,000 $17,500 $200,000 $25,000
CICRF is the payor of last resort, meaning expenses covered by other sources (such as insurance and fundraising) or that are the responsibility of other state or federal programs (such as the Department of Education), are not considered. The date of all expenses and payments must occur within 24 months before the date this application is submitted and before the child/youth's 22nd birthday.
You will be asked for proof of payment, invoices and other information for each expense selected from the list below. CICRF policy limits the amounts counted toward eligibility, and reimbursement is on a sliding scale for some expenses such as vehicle purchases, home modifications and whole-house generators.
Eligible Expenses Ineligible Expenses
Commonly Reimbursed Expenses:
Family Support: The Fund can provide a daily rate depending on distance traveled for expenses associated with visiting the hospital for inpatient or outpatient care.
Accessible Vehicles: T he Fund can consider expenses related to purchasing and/or modifying a vehicle if your child uses a wheelchair or travels with mobility or other durable medical equipment requiring additional storage space.
Home Modifications: The Fund can consider modifications such as an accessible bedroom or bathroom, wheelchair ramp or widened doorways.
Medical Equipment & Supplies: The Fund can consider expenses for uncovered medical equipment (such as stairlifts, generators and ceiling lifts), uncovered medical supplies, and medication (self-pay, copays/coinsurance/deductibles).
Medical Expenses: The Fund can consider expenses such as uncovered hospital, physician, laboratory, ambulance and therapy expenses (self-pay, copays/coinsurance/deductibles) .
Funeral Expenses: The Fund can consider in-state expenses to cover services, burial plots, memorials for families, up to $10,000 only for families earning less than 400% Federal Poverty Income Guidelines (FPIG).
CommonHealth and MassHealth premiums: The Fund can consider expenses for CommonHealth and MassHealth premiums for families not receiving Premium Assistance; private health insurance premiums are not covered.
Lodging expenses: The Fund can consider lodging if you live more than 50 miles one way from the provider.
Please see the list of eligible expenses here:
Please see the list of ineligible expenses here:
What expenses are you applying for?
* must provide value
Other expense(s):
* must provide value
Has there been any fundraising on behalf of your child for the expenses requested, such as through online fundraising platforms (GoFundMe, CrowdRise), community events, hospitals, individuals, grants or other organizations?
* must provide value
Yes
No
Source of Fundraising Fundraising for which expense category? Amount Raised to Date Source 1: Source 2: Source 3:
Fundraiser Source #1:
* must provide value
Fundraising expense category #1
* must provide value
Fundraising Expense Other 1
Fundraising Expense Other 2
Fundraising Expense Other 3
Fundraising Amount #1:
* must provide value
Family Support
Estimated number of inpatient days within the last 24 months:
Estimated number of outpatient days within the last 24 months:
Family Support - Inpatient days
* must provide value
Family Support - Outpatient days
* must provide value
Accessible Vehicles
What type of vehicle expenses are you applying for?
Total amount of purchase and/or modification(s):
Date of Purchase:
Date of Modification:
Documentation Required
Dealer invoice/bill of sale(s):
Proof of your payment(s) for the vehicle:
Initial deposits (your bank/credit card statement, canceled checks) Balance due for vehicle (your bank/credit card statement, canceled check copies)
All loan agreements (if financed):
If financed, documentation of a recent payment for all loans (canceled check, bank or loan statement):
Photos of vehicle, modifications and/or any equipment transported:
Copy of the Massachusetts vehicle registration:
Letter from child/youth's physician describing medical condition and need for accessible vehicle:
What type of vehicle expenses are you applying for?
* must provide value
Purchase of a modified vehicle (e.g. a vehicle with a ramp already installed) Purchase of an unmodified vehicle Cost of modification to a vehicle Purchase of an unmodified vehicle AND cost of modification to a vehicle
Total Vehicle Amount:
* must provide value
Vehicle Purchase Date 1:
* must provide value
Today M-D-Y
Today M-D-Y
Dealer invoice/bill of sale for accessible vehicle or modification
* must provide value
Dealer Invoice/Bill of Sale 2:
Dealer Invoice/Bill of Sale 3:
Proof of payment for accessible vehicle or modification
* must provide value
Proof of payment #2 (Vehicle)
Proof of payment #3 (Vehicle)
Proof of payment #4 (Vehicle)
Picture of accessible vehicle or modification
* must provide value
Picture of the vehicle modification
Vehicle registration
* must provide value
Letter of medical necessity for accessible vehicle or modification
* must provide value
Catastrophic Illness in Children Relief Fund Vehicle Purchase/Modification Statement
Please initial the four items listed bellow.
I hereby swear under the pains and penalties of perjury that:
Parent/Guardian Initials
1) The vehicle was paid for by the parent/guardian. If financed, the parent/guardian is making the monthly payments on the vehicle.
2) The vehicle is in my/our possession and is being used solely for my/our family's personal use to transport my/our child who was under 22 years of age at the time of the expense.
3) Check all that apply. The vehicle was purchased because my child:
Wheelchair, make and model # (if applicable):
Make and model # of any medical and/or adaptive equipment (if applicable):
Vehicle statement initials
* must provide value
Vehicle statement initials
* must provide value
Vehicle statement intials
* must provide value
Reason for vehicle purchase or modification
* must provide value
Wheelchair make and model #
What type of modifications did you make to your home?
* must provide value
Interior home modification Exterior home modification Both interior and exterior home modifications
What type of interior home modifications were made?
* must provide value
What type of exterior home modifications were made?
* must provide value
Interior Home Modification Expenses Total Expense:
Start Date:
End Date:
Documentation Required Statement(s) from the contractor (if any) or parent/guardian, describing the areas modified and itemizing the expenses for each project (e.g. accessible bathroom):
Receipts and proof of payment for materials and labor (vendor statements, canceled checks, bank statements, credit card receipts/statements) related to the project:
Pictures of the modifications:
If financed, copy of lender's installment or loan agreement
If financed, documentation of a recent loan payment (canceled check, bank or loan statement):
Letter from child/youth's physician describing the medical need for the home modification project:
Interior home modification total
* must provide value
Interior home modification start date
* must provide value
Today M-D-Y
Interior home modification end date
* must provide value
Today M-D-Y
Interior home modification statement or description of project
* must provide value
Interior home modification: itemized receipts/documentation of payments
* must provide value
Itemized receipts for all supplies and documentation of payment (bank, credit card statements)
Itemized receipts for all supplies and documentation of payment (bank, credit card statements)
Itemized receipts for all supplies and documentation of payment (bank, credit card statements)
Interior home modification photos
* must provide value
Letter of medical necessity for interior home modification
* must provide value
Exterior Home Modification Expenses Total expense:
Start Date:
End Date:
Documentation Required Statement(s) from the contractor (if any) or parent/guardian, describing the areas modified and itemizing the expenses for each project (e.g. exterior ramp):
Receipts and proof of payment for materials and labor (vendor statements, canceled checks, bank statements, credit card receipts/statements) related to the project:
Pictures of the modifications:
If financed, copy of the lender's installment or loan agreement:
If financed, documentation of a recent loan payment (canceled check, bank or loan statement):
Letter from child/youth's physician describing the medical need for the home modification project:
Exterior home modification total cost:
* must provide value
Exterior home modification start date
* must provide value
Today M-D-Y
Exterior home modification end date
* must provide value
Today M-D-Y
Exterior home modification statement or description of project
* must provide value
Exterior home modification: itemized receipts and documentation of payments
* must provide value
Itemized receipts for all supplies and documentation of payment (bank, credit card statements)
Itemized receipts for all supplies and documentation of payment (bank, credit card statements)
Itemized receipts for all supplies and documentation of payment (bank, credit card statements)
Exterior home modification photos
* must provide value
Letter of medical necessity for exterior home modification
* must provide value
Catastrophic Illness in Children Relief Fund Home Modification Statement
Please initial the four items listed.
I hereby swear under the pains and penalties of perjury that:
Parent/Guardian #1 initial
1) The home modification has been completed.
2) The home modification has been done on my permanent home.
3) The home modification was done to increase accessibility or safety for my child who was under 22 years of age at the time of the expense.
4) If I sell my home within 3 years, I will contact CICRF, and it is likely that I will need to return 50% of the assistance to the Fund.
Home modification statement initials
* must provide value
Home modification statement initials
* must provide value
Home modification statement initials
* must provide value
Home modification statement initials
* must provide value
Medical Equipment and Supplies Item #1
Item Description:
Item Cost:
Date of purchase:
Item #2
Item Description:
Item Cost:
Date of purchase: Item #3
Item Description:
Item Cost:
Date of purchase: Item #4
Item Description:
Item Cost:
Date of purchase: Item #5
Item Description:
Item Cost:
Date of purchase:
Medical Equipment and Supplies Description: Item 1
* must provide value
Medical Equipment and Supplies Description: Item 2
Medical Equipment and Supplies Description: Item 3
Medical Equipment and Supplies Description: Item 4
Medical Equipment and Supplies Description: Item 5
Medical Equipment and Supplies Amount: Item 1
* must provide value
Medical Equipment and Supplies Amount: Item 2
Medical Equipment and Supplies Amount: Item 3
Medical Equipment and Supplies Amount: Item 4
Medical Equipment and Supplies Amount: Item 5
Medical Equipment and Supplies Date of Purchase: Item 1
* must provide value
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Medical Expenses
Medical Expense #1
Description:
Total Expense:
Start date of service/expense:
End date of service/expense (if applicable):
Medical Expense #2
Description:
Total Expense:
Start date of service/expense:
End date of service/expense (if applicable):
Medical Expense #3
Description:
Total Expense:
Start date of service/expense:
End date of service/expense (if applicable):
Medical Expense #4
Description:
Total Expense:
Start date of service/expense:
End date of service/expense (if applicable):
Medical Expense #5
Description:
Total Expense:
Start date of service/expense:
End date of service/expense (if applicable):
Medical Expense Description: Item 1
* must provide value
Medical Expense Amount: Item 1
* must provide value
Medical Expense Purchase/Start Date: Item 1
* must provide value
Today M-D-Y
Medical expense purchase end date 1
Today M-D-Y
Medical expense purchase date 2
Today M-D-Y
Medical expense purchase end date 2
Today M-D-Y
Medical expense purchase date 3
Today M-D-Y
Medical expense purchase end date 3
Today M-D-Y
Medical expense purchase date 4
Today M-D-Y
Medical expense purchase end date 4
Today M-D-Y
Medical expense purchase date 5
Today M-D-Y
Medical expense purchase end date 5
Today M-D-Y
Funeral/Burial Expenses
What type of expenses do you have? Check all that apply.
Total Expenses:
Expense Timeframe
Start date:
End date:
Funeral Home Expenses
Invoices and/or itemized receipts:
Proof of payment (receipts, credit card statements, canceled checks, paid invoices):
Cemetery Costs
Invoices and/or itemized receipts:
Proof of payment (receipts, credit card statements, canceled checks, paid invoices):
Monument, Head Stone or Marker Expenses
Invoices and/or itemized receipts:
Proof of payment (receipts, credit card statements, canceled checks, paid invoices)
Funeral Expenses
* must provide value
Funeral Total Cost:
* must provide value
Funeral expenses start date
* must provide value
Today M-D-Y
Funeral expenses end date
* must provide value
Today M-D-Y
Funeral home invoice or itemized receipts
Funeral home proof of payment
Cemetery related invoices or itemized receipts
Cemetery related proof of payment
Monument related invoices or itemized receipts
Monument related proof of payment
CommonHealth, MassHealth and CMSP Premiums
Total Amount:
Dates of Service
Start Date:
End Date:
Documentation Required Insurance premium statements or proof of payment (credit card receipts or statements, canceled checks, bank statments, etc.):
Insurance premium amount
* must provide value
Insurance premium(s) start date
* must provide value
Today M-D-Y
Insurance premium(s) end date
* must provide value
Today M-D-Y
Insurance premium statement(s) or proof of payment
Lodging
Lodging expenses can be submitted if you live 50 miles or more from the provider or treating facility.
Lodging Stay #1 Total Expenses: Lodging Dates
Check-in date:
Check-out date:
Billing statements, receipts or invoices with the parent/guardian's name and the lodging dates:
Credit card receipts & statements, canceled checks, bank statements:
Lodging Stay #2 Total Expenses: Lodging Dates
Check-in date:
Check-out date:
Billing statements, receipts or invoices with the parent/guardian's name and the lodging dates:
Credit card receipts & statements, canceled checks, bank statements:
Lodging Stay #3 Total Expenses: Lodging Dates
Check-in date:
Check-out date:
Billing statements, receipts or invoices with the parent/guardian's name and the lodging dates:
Credit card receipts & statements, canceled checks, bank statements:
Lodging Stay #4 Total Expenses: Lodging Dates
Check-in date:
Check-out date:
Billing statements, receipts or invoices with the parent/guardian's name and the lodging dates:
Credit card receipts & statements, canceled checks, bank statements:
Lodging Stay #5 Total Expenses: Lodging Dates
Check-in date:
Check-out date:
Billing statements, receipts or invoices with the parent/guardian's name and the lodging dates:
Credit card receipts & statements, canceled checks, bank statements:
Lodging Stay #6 Total Expenses: Lodging Dates
Check-in date:
Check-out date:
Billing statements, receipts or invoices with the parent/guardian's name and the lodging dates:
Credit card receipts & statements, canceled checks, bank statements:
Lodging Amount - Stay #1:
* must provide value
Lodging start date
* must provide value
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Lodging end date
* must provide value
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Lodging billing statements or invoices
* must provide value
Lodging receipts or proof of payment
* must provide value
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
Credit card receipts & statements, canceled checks, bank statements
What is your total annual household income before taxes? Include your income, your partner's income, and any other income you may have received (e.g., SSI, TAFDC, SNAP, child support).
* must provide value
< $25,000
$25,000 - $34,999
$35,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000 and above
How many people does your household income support?
Adults age 18 or older:
Children age 17 or younger:
How many people does your household income support that are adults (age 18 or older)?
* must provide value
1 2 3 4 5 6 7 8 9 10
How many people does your household income support that are children (age 17 or younger)?
* must provide value
0 1 2 3 4 5 6 7 8 9 10
The option "
During the past 24 months, what were the sources of income for your household? Please select all that apply.
* must provide value
During the past 24 months, has your household received money from fundraising/donations for living expenses?
* must provide value
Yes
No
If you do not have any income to report, please describe your living situation.
* must provide value
Please specify other income source:
* must provide value
Federal Tax Return
Please upload all tax returns filed by parent/guardians for the past 2 years. Federal tax return #1 (including paystubs and W-2's) Year of tax return:
Federal tax return #2 (including paystubs and W-2's) Year of tax return:
Federal tax return #3 (including paystubs and W-2's) Year of tax return:
Federal tax return #4 (including paystubs and W-2's) Year of tax return:
Federal Tax Return 1 - Year
* must provide value
Copy of Federal Tax Return Upload
* must provide value
Federal Tax Return Upload 1b
Federal Tax Return Upload 2a
Federal Tax Return Upload 2b
Federal Tax Return Upload 3a
Federal Tax Return Upload 3b
Federal Tax Return Upload 4a
Federal Tax Return Upload 4b
Supplemental Security Income (SSI)
Family Member #1 Name: Annual award letter(s): Family Member #2 Name: Annual award letter(s): Family Member #3 Name: Annual award letter(s): Family Member #4 Name: Annual award letter(s): Family Member #5 Name: Annual award letter(s):
SSI Family Member Name #1
* must provide value
SSI Family Member Name #2
SSI Family Member Name #3
SSI Family Member Name #4
SSI Family Member Name #5
Family Member #1 - SSI Award Letter
* must provide value
Family Member #1 - SSI Award Letter 1b
Family Member #2 - SSI Award Letter 2a
Family Member #2 - SSI Award Letter 2b
Family Member #3 - SSI Award Letter 3a
Family Member #3 - SSI Award Letter 3b
Family Member #4 - SSI Award Letter 4a
Family Member #4 - SSI Award Letter 4b
Family Member #5 - SSI Award Letter 5a
Family Member #5 - SSI Award Letter 5b
Social Security or Social Security Disability (SSDI)
Family Member #1 Name: Annual award letter or Social Security or SSDI 1099 statement: Family Member #2 Name: Annual award letter or Social Security or SSDI 1099 statement: Family Member #3 Name: Annual award letter or Social Security or SSDI 1099 statement: Family Member #4 Name: Annual award letter or Social Security or SSDI 1099 statement: Family Member #5 Name: Annual award letter or Social Security or SSDI 1099 statement:
SSDI Family Member Name #1
* must provide value
SSDI Family Member Name #2
SSDI Family Member Name #3
SSDI Family Member Name #4
SSDI Family Member Name #5
Family Member #1 - Copy of SSDI Documentation
* must provide value
Family Member #1 - SSDI Documentation
Family Member #2 - SSDI Documentation
Family Member #2 - SSDI Documentation
Family Member #3 - SSDI Documentation
Family Member #3 - SSDI Documentation
Family Member #4 - SSDI Documentation
Family Member #4 - SSDI Documentation
Family Member #5 - SSDI Documentation
Family Member #5 - SSDI Documentation
Department of Transitional Assistance (for SNAP, TAFDC or EAEDC benefits)
Please download and complete the DTA release form:
Please upload the completed DTA release form here:
DTA Release Form
* must provide value
Child Support / Alimony
Child Support Amount: Court order, DOR payment history, or signed letter from non-custodial parent explaining payments to custodial parent:
Child Support - Amount Received:
* must provide value
Child Support Documentation
* must provide value
Child Support Documentation 2
Short-/Long-term Disability
Family Member #1 Name of family member receiving income: Amount received: How often: Copy of 1099:
Family Member #2 Name of family member receiving income: Amount received: How often: Copy of 1099:
Short/Long-term Disability Family Member Name #1
* must provide value
Short/Long-term Disability Family Member Name #2
Short/Long-term Disability Family Member Name #1 (Amount)
* must provide value
Short/Long-term Disability Family Member Name #2 (Amount)
Short/Long-term Disability Family Member Name #1 (Frequency)
* must provide value
Weekly Monthly Yearly
Short/Long-term Disability Family Member Name #2 (Frequency)
Weekly Monthly Yearly
Short/Long-term Disability Family Member Name #1 (1099 Statement)
* must provide value
Short/Long-term Disability Family Member Name #1 (1099 Statement 1b)
Short/Long-term Disability Family Member Name #2 (1099 Statement 2a)
Short/Long-term Disability Family Member Name #2 (1099 Statement 2b)
Workers' Comp
Family Member #1 Name of family member receiving income: Amount received: How often: Copy of the Worker's Compensation award letter which specifies the weekly compensation amount: Family Member #2 Name of family member receiving income: Amount received: How often: Copy of the Worker's Compensation award letter which specifies the weekly compensation amount:
Worker's Comp Family Member #1 (Name)
* must provide value
Worker's Comp Family Member Name #2
Worker's Comp Family Member #1 (Amount)
* must provide value
Worker's Comp Family Member #2 (Amount)
Worker's Comp Family Member #1 (Frequency)
* must provide value
Weekly Monthly Yearly
Worker's Comp Family Member #2 (Frequency)
Weekly Monthly Yearly
Worker's Comp Family Member #1 (Compensation award letter)
* must provide value
Worker's Comp Family Member #1 (Compensation award letter)
Worker's Comp Family Member #2 (Compensation award letter)
Worker's Comp Family Member #2 (Compensation award letter)
Pension/Retirement Income
Family Member #1 Name: Amount received: How often: Copy of 1099: Family Member #2 Name: Amount received: How often: Copy of 1099:
Pension/Retirement Income Family Member #1 (Name)
* must provide value
Pension/Retirement Income Family Member #1 (Amount)
* must provide value
Pension/Retirement Income Family Member #1 (Frequency)
* must provide value
Weekly Monthly Yearly
Pension/Retirement Income Family Member #1 (1099 Statement)
* must provide value
Pension/Retirement Income Family Member #1 (1099 Statement)
Pension/Retirement Income Family Member Name #2
Pension/Retirement Income Family Member #2 (Amount)
Pension/Retirement Income Family Member #2 (Frequency)
Weekly Monthly Yearly
Pension/Retirement Income Family Member #2 (1099 Statement)
Pension/Retirement Income Family Member #2 (1099 Statement)
Veteran's Benefits
Family Member #1 Name of family member receiving income: Amount received: How often: Family Member #2 Name of family member receiving income: Amount received: How often:
Veteran's Benefits Family Member #1 (Name)
* must provide value
Veteran's Benefits Family Member Name #2
Veteran's Benefits Family Member #1 (Amount)
* must provide value
Veteran's Benefits Family Member #2 (Amount)
Veteran's Benefits Family Member #1 (Frequency)
* must provide value
Weekly Monthly Yearly
Veteran's Benefits Family Member #2 (Frequency)
Weekly Monthly Yearly
Paid Family Medical Leave
Family Member #1 Name: Amount received: How often: PFML payment history report: Family Member #2 Name: Amount received: How often: PFML payment history report:
Paid Family Medical Leave Family Member Name #1
* must provide value
Paid Family Medical Leave Family Member #1 (Amount)
* must provide value
Paid Family Medical Leave Family Member #1 (Frequency)
* must provide value
Weekly Monthly Yearly
Paid Family Medical Leave Family Member #1 (Payment History Report)
* must provide value
Paid Family Medical Leave Family Member Name #2
Paid Family Medical Leave Family Member #2 (Amount)
Paid Family Medical Leave Family Member #2 (Frequency)
Weekly Monthly Yearly
Paid Family Medical Leave Family Member #2 (Payment History Report)
HOUSEHOLD INFORMATION This section will ask you questions about your household, who lives there and where your child regularly sleeps.
Which of the following best describes your household?
* must provide value
Single-parent/guardian
Two-parent/guardian
For each member of the household, please list their full name, date of birth and relationship to the applicant. Do not include the applicant (child) below.
Name (First and Last) Date of Birth
(month / day / year)
Relationship to Child
Household member name
* must provide value
Household member date of birth
* must provide value
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Household member relationship to child
* must provide value
Parent Legal guardian Step-parent Sibling Grandparent Other relative Friend Other
Parent Legal guardian Step-parent Sibling Grandparent Other relative Friend Other
Parent Legal guardian Step-parent Sibling Grandparent Other relative Friend Other
Parent Legal guardian Step-parent Sibling Grandparent Other relative Friend Other
Parent Legal guardian Step-parent Sibling Grandparent Other relative Friend Other
During the past 30 days, where did your child usually sleep at night? (Choose ONE. If more than one place, choose the one where they slept most often.)
* must provide value
In their parent's or guardian's home
With a friend, family, or other people because we lost our home and cannot afford housing
In a shelter or emergency housing
In a hotel/motel, car, park, campground, or other public space
In a foster home or residential placement
In a hospital or skilled nursing facility
In a group home
They moved from place to place
Somewhere else, please specify
Decline to answer
Please specify other place child sleeps:
* must provide value
ADDITIONAL HEALTH & FAMILY INFORMATION In this section, we will ask about your mental and physical health and if you have concerns about other children in the home. This information will help us support you and your family by connecting you to other programs you are eligible for within the Division for Children and Youth with Special Health Needs.
In general, how would you rate your physical health?
* must provide value
Excellent Very Good Good Fair Poor Decline to answer
In general, how would you rate your mental health?
* must provide value
Excellent Very Good Good Fair Poor Decline to answer
Do you have any health or other concerns about any other children in your household?
* must provide value
No concerns Some concerns A great deal of concerns There are no other children in the household Decline to answer
Please specify concerns:
* must provide value
DEMOGRAPHIC INFORMATION To ensure everyone gets the highest quality treatment and services, we are collecting information on each child's race and ethnicity. Please complete the next several questions about your child. This information will be kept confidential.
Is your child Hispanic/Latinx? Latinx is a gender-neutral term to refer to a Latino/Latina person.
* must provide value
Yes No Do not know Decline to answer
What is your child's ethnicity? (You can specify one or more). Ethnicity represents your ethnic origin or descent, heritage, nationality, or the place of birth of your child or your child's ancestors.
The option "
Please specify African ethnicity:
* must provide value
Please specify Caribbean ethnicity:
* must provide value
Please specify Middle Eastern ethnicity:
* must provide value
Please specify other ethnicity:
* must provide value
The option "
What is your child's race? (You can specify one or more).
* must provide value
Specify tribal nation
* must provide value
Please specify Native Hawaiian or other PI:
* must provide value
Please specify other race:
* must provide value
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