Emergency Financial Assistance - Cancer Support Community San Francisco Bay Area

Cancer Support Community is now providing emergency financial assistance to low-income cancer patients and their families.

A social worker, doctor, or other licensed medical provider must complete the intake form for the patient and make the request. Funds are limited. For more information please call 925.933.0107.

To qualify, the applicant must:

Be diagnosed with breast cancer.
Reside in Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, or Sonoma Counties.
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).
Be actively in treatment for cancer or will be in active treatment in the next six months. In some situations, the support may be extended to cancer survivors who have completed treatment in the last six months.

Emergency Financial Assistance Application

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 $250.

How will the funds be used?(Required)

CAPTCHA

This program is made possible by: