Beneficiary Form

Personal details

Full name*

Upload Your Photo*

Date of Birth*

Marital Status*

Gender*

Religion*

Occupation*

Nationality*

Salary*

Total family Members*

Total Family Income*

No. of Family Members Working*

Address Details

Type of Accommodation

Area

Emirate

Building Name / Number

No of Rooms

Landmark

Rent / Month

Rent / Year

Mobile Number

Residence Phone Number

Work Phone Number

Health Details

Type of Cancer

Date of Diagnosis

Type of Treatment

Health Insurance

Health Insurance Provider

Health Insurance Expiry Date

Health Card

Health Card Type

Health Card Expiry Date

Treating Hospital

Name of Treating Doctor

Treating Doctor Contact no.

UAE Residency for Non-Locals

Visa Number

Visa Expiry Date

Emirates ID number

Emirates ID Expiry

Sponsor Name

Sponsor Phone Number

Sponsor Relation with Patient

Did you apply to another charity before

Applied charity Name

Name of the person you are in contact with in FOCP

How did you hear about FOCP

Contact person in case of emergency

Name

Relation

Contact Number

Kind of Support Requested from FOCP

Support Requested

Other (Please Specify)

Entity Name

Kind of Treatment

Total Treatment Costs

Insurance Co-Payment %

Insurance amount coverage

Patient Co-Payment %

Patient Co-Payment Amount

Attachments Needed to Open a File

Request Letter Explaining the case*

Two Personal Photos*

Residence Page & Passport Copy*

Copy of National ID*

Treatment Quotation / Cost Estimate*

Health Card*

Insurance Card Copy*

An official letter from the insurance company* (stating if the insurance will not cover / or if it covers only a portion of the treatment’s cost.)

Medical Report (no older than 6 months)*

Passport and visa copies for all family members*

Company License* (For patients or any family members whose visa states that they are a "Partner" or "Investor")

Patient Salary Certificate (Not older than 6 months)*. If patient is not working, please write a 'Declaration letter' confirming the same + signed

Salary certificates for all working family members*

Bank Statement for the company*

Patient's last 3 months bank statement*

All working family members last 3 months bank statements*

Father Husband / Passport Copy*

Tenancy Contract (Must be valid)*

Terms

Please note the application file will be examined only after the submitting all required documents (In case if any of the documents were not provided, the application file will not be accepted)
I do understand that any support for treatment in the UAE or aboard will take some time to be processed. Please note that FOCP will have to contact the ministry of foreign affairs to check the money transfer process to the hospital abroad as all funds should be transferred from the UAE embassy in that country
Any changes in current status, I am obligated to inform the charity about these changes or submit any documents if necessary.
I pledge that all details submitted are correct and will take full responsibility of the legal consequences if is was found otherwise
I understand that the file will undergo a review process for a period of time, and that FOCP is liable to provide any justification for applicants in case if the application was rejected

I have read and agree to the Terms

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