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Application Form

Eligibility Criteria

Thank you for choosing Bradford Cares to support your treatment journey. Our Financial Assistance program is available to assist individuals recovering from substance abuse with the costs of treatment services and/or related costs (e.g. sober living housing fees, transportation etc.) (collectively, the “Treatment Costs”), without regard to age, race, color, creed, sex, religion, ancestry, marital status, disability, national origin or other legally protected category. Eligibility is income-based and subject to verification of the following (the “Eligibility Criteria”):

1.
Applicant is enrolled in and/or discharged from a substance use disorder treatment program to receive detoxification and/or residential treatment services in the past sixty (60) days and continues to actively receive treatment services for substance use disorder as of the time of the application and/or medical necessity for prospective treatment services for substance use disorder has been verified via the use of guidelines established by licensed health care professionals and/or medical societies and other professional bodies (e.g., ASAM, etc.);
2.
Prospective, current and/or previous treatment services for substance use disorder are/were ordered by a licensed health care professional specializing in addiction medicine and/or determined to be necessary via the use of guidelines established by licensed health care professionals and/or medical societies and other professional bodies (e.g., ASAM, etc.);
3.
Prospective, current and/or previous treatment services for substance use disorder are/were provided at an institution/facility licensed to provide such services as required by applicable local, state, and/or federal laws, statutes, regulations, ordinances and/or rules and/or accredited by a recognized accreditation agency that is qualified to accredit institutions/facilities as providers of treatment services for substance use disorder (e.g., The Joint Commission, CARF); and
4.
Applicant has incurred and/or will incur costs for fees that include the charges and costs of treatment services (e.g., co-payment, deductible, etc.) or costs for items, supplies, and/or services that are directly related to treatment services and recommended by a licensed health care professional and/or determined to be necessary in facilitating or coordinating treatment services.

If you have met the Eligibility Criteria above, we will need the following documents to process your Application:

  1. A completed Application for Financial Assistance.
  2. Proof of enrollment and/or discharge in a qualified substance use disorder treatment program in the past sixty (60) days.
  3. Copies of invoices for Treatment Costs and/or outstanding balances for the costs of treatment services or costs for items, supplies, and/or services directly related to treatment services and/or an estimate of costs of prospective treatment services and/or related items, supplies, and/or services.
  4. Verification of all income, such as a copy of your most recent paycheck, Social Security and/or other governmental checks, pensions, child support checks, etc.
  5. A copy of your most recent Federal income tax return.
  1. A copy of your most recent bank (checking and/or savings) statement.
  2. Driver’s license or identification card.
  3. Application Letter including the following information:

    a. Description of the reason/purpose applicant is seeking financial assistance from Bradford Cares.

    b. Description of history of addiction and how resources from Bradford Cares will impact applicant’s recovery journey if awarded.

    c. Description of previous treatment episodes and/or attempts at recovery, including what barriers impacted success and what will be different if the applicant receives resources from Bradford Cares.

    d. Description of any immediate stressors the applicant is experiencing that are attributable to active addiction/use (such as pending/active legal issues, child custody matters, lack of employment, housing instability, and/or financial hardship).

    e. Description of how the applicant will assist others in need when able to do so if the applicant receives resources from Bradford Cares.

  4. Treatment records from previously treatment episodes/providers (within the last two years).
  5. Letters of Support from a personal and professional contact (e.g., social worker, current/previous provider, etc.) addressing the relationship between parties and expected benefit of the applicant receiving assistance from Bradford Cares.

An Application for Financial Assistance is enclosed for you to complete and return. All Applications are subject to verification. If you provide false information your Application will be denied and you will not be allowed to reapply in the future.