ASSISTANCE

“Children’s Body-Image Foundation Financial Assistance”

Fax: (614) 855-6122

Request Form*

* To open the request form you need Adobe Acrobat Reader (it’s free):

Children’s Body-Image Foundation ONLY provides financial assistance for those allied medical healthcare services outlined in our mission, purpose statement, and related to body image awareness and self esteem issues. These allied medical services MUST be associated with a related diagnosis by a licensed, practicing physician. We will work with you and your healthcare service(s) provider to verify and establish financial need.

* The steps are easy! Just read our criteria for financial assistance then click on our request form above, print it, answer the questions, sign it, and then fax it to us at 614-855-6122.

[CRITERIA for FINANCIAL ASSISTANCE]

Demonstrate financial need/hardship, “Financial Need” means:  Any child or family with a child, experiencing a financial burden in direct relationship to providing allied medical healthcare services for a burdened child or family. This may be due to but NOT limited to:

1) Parents or guardians who are unemployed and without the appropriate government assistance for those allied medical healthcare services related to body image awareness and self esteem issues and/or outlined by our mission and purpose statement.

-OR-

2) Parents or guardians who are employed but indigent and/or without sufficient medical insurance.

-OR-

3) Families whose income falls below 250% of Health and Human Services Poverty Guidelines^* (click HERE for guidelines) for family income and MAY include a signed and filed copy of your personal tax return:

You may apply for financial assistance with Children’s Body-Image Foundation by:

A) Having an allied medical healthcare services provider, parent/guardian, or adult submit a financial assistance application/form on behalf of the family/child.  By doing this you agree/allow for us to communicate with any and all persons, including but not limited to any related allied healthcare provider regarding the diagnosis and the need for assistance at our discretion.

-OR-

B) You may apply for financial assistance directly via our website utilizing our financial request form. You may submit this form to us for review at: 5195 Hampstead Village Center Way #106 New Albany, OH 43054. Once we receive the form we will contact you.  By applying for financial assistance you agree to allow us to communicate with your allied healthcare provider regarding your child’s diagnosis and your need for assistance.

[PROGRAMS for ASSISTANCE]

1) The “Medical Insurance Deductible Program” provides financial assistance paid directly to your allied medical healthcare services provider.  This financial assistance is provided to families who have demonstrated financial need (please see financial need outline above) in paying for their healthcare insurance deductible in accordance with our foundation’s mission and purpose.

 2) The “Financial Assistance Program” provides financial assistance (preferably) directly to allied medical services providers to assist those families who have demonstrated financial need with assistance in the payment of their allied medical services expenses in accordance with our foundation’s mission and purpose and related to body image awareness and self esteem issues.  This assistance may be initiated by “ANY” qualified allied medical services provider, or the child’s parent/guardian.  In an effort to avoid the possibility of any financial assistance provided by Children’s Body-Image Foundation to be assessed as income for participating families, we PREFER to pay allied medical services providers directly, but reserve the right to pay the family directly.  However, the previous statement should not be regarded as tax advice and we advise you consult your tax professional to determine the proper tax treatment of any and all assistance received by Children’s Body-Image Foundation.  This program DOES apply to elective surgeries/services.

3) The “Allied Medical Services & Nonprofit Organizations Program” This program establishes a professional relationship between Children’s Body-Image Foundation and any qualified/appropriate allied medical services provider and/or professional nonprofit 501c3 organization who wants to participate in this program.  These allied medical services providers and nonprofit organizations are identified and participate in this program because we have established that they provide services according to our mission and purpose statements. The relationship between these allied medical providers, and/or, nonprofit organizations and our foundation is strictly voluntary. Any qualified allied medical services provider and/or professional nonprofit organization can participate in this program as long as they provide those allied medical services recognized by our organization, hold all appropriate licensures, and are recognized for practicing in their respective professions. No board member for Children’s Body-Image Foundation is associated with or has any professional interest in any of these providers or nonprofit organizations.  All transactions are conducted while adhering to common practices of professional ethical standards. We DO NOT give preference to any qualified allied medical healthcare service provider or nonprofit organization. If we use their logo, we utilize their logo via our website ONLY to show that they provide such services to children.  If your organization would like to become a-partner with our foundation please contact us. The foundation at its discretion may choose to provide a financial award to any professional 501c3 nonprofit organization that it believes accurately represents its mission and purpose for their use in any of its services as specifically directed by Children’s Body-Image Foundation.

If you are approved for financial assistance you may use any healthcare insurance company/allied medical services provider you choose as long as they meet our criteria for provider.  Upon participation in our program a voluntary disclosure by the family requesting financial assistance (a signed and filed copy of your personal tax return, current employment pay stubs, unemployment paperwork, and any other necessary and appropriate paperwork) MAY be asked to be submitted to us as part of the evaluation process.  Also, the participating allied medical healthcare provider rendering services to the child MUST certify that the treatment meets our guidelines (if applicable). We also prefer to reimburse healthcare providers directly as to avoid assistance counted as personal income to the family, but it is NOT required.  However, the previous statement should not be regarded as tax advice and we advise you consult your tax professional to determine the proper tax treatment of any and all assistance received by Children’s Body-Image Foundation.  If payment has already been made to the provider, and all other conditions herein have been met, you may make a request for reimbursement by submitting the following information: 1) Application for Assistance Form 2) Proof of Payment

In our efforts to improve and strengthen our growth and in order for us to help as many children as possible, we have initially set a reserve of our funds of 25%. As such, 25% of our funds will be kept in reserve and all contributions that we receive beyond the reserve (75%) will be paid out as outlined in our foundation’s mission and purpose and financial assistance programs.  It is anticipated 100% of all contributions/donations will eventually be allocated towards the successful operation of our foundation.  We will continuously evaluate our position regarding payouts versus reserves and make (if any) necessary changes accordingly. The order of any eligible financial assistance will be on a first come, first serve basis.

Our financial assistance program has a cap of up to $500.00* per child per claim.  Therefore, those familys whose claims have been approved by our foundation may be eligible for assistance in the future (after a period of no less than 6 months) if the child requires refitting, continuity of care, or other related services in the future until the recipient reaches age 18. If you believe that you qualify for assistance we strongly encourage you to apply.  The application for assistance is on a first come, first serve basis.  Unfortunately if an application is received when we do not have any funds available it will be denied.  We will not hold applications open until funds become available. Each family should reapply each time they need assistance.

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* Children’s Body-Image Foundation reserves the right to not pay on a claim, and or, has the final decision making authority to determine which claims are paid.