Emergency Financial Assistance Application

A social worker, doctor, or other medical provider must fill out the application below on behalf of the applying patient. By applying you confirm that they meet the qualifying criteria.

Date

Provider Name(Required)

First Last Title/Credential

A social worker, doctor, or other medical provider must fill out the application on behalf of the patient.

Hospital or Medical Institution(Required)

Provider Email Address(Required)

Provider Phone Number(Required)

Patient Details

Patient Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Please ensure email is listed correctly.

Phone(Required)

Cancer Type

Date of Diagnosis

Is the patient actively in treatment for cancer or will they be in active treatment in the next six months?(Required)

Date Treatment Started(Required)

Ethnicity

Age

Date of Birth

Income

Must have a low income as defined by the U.S. Department of Housing and Urban Development (HUD) standards (income level of $76,750 or less).

Source of Income

Insurance Type

HMO

Medicare

Medical

None

Award Type(Required)

Gift Card (Gift cards limited to Safeway, Target, Trader Joes, Costco)

Rent Assistance (payable directly to landlord)

Utilities Assistance (payable directly to provider)

If a gift card is the preferred option, please select which gift card you would like to receive.

If a gift card is the preferred option, please select delivery method.

If applicable, who should the check be made out to?(Required)

Checks will be made payable directly to landlord, utility or phone company, etc. Checks will not be issued directly to patients.

Amount Requested(Required)

The maximum award granted is between $200-500.

How will the funds be used?(Required)

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