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 outlined in our program guidelines.

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

Phone(Required)

Cancer Type

Date of Diagnosis

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

Who should the check be made out to?(Required)

Checks will be made payable directly to landlord, utility company, phone, medical provider, etc. A gift card option is also available.

Amount Requested(Required)

The maximum award granted is $500.

How will the funds be used?(Required)

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