Application for Financial Aid

Application for Financial Aid

Chemocharity.org
What We Do...

The Chemocharity mission is to provide help and hope to cancer patients in meeting their daily needs as well as during holiday seasons when the stress of medical bills and treatment place an even heavier burden on families during a time which should only be filled with celebration and joy.
How It Works...

We ask that you please fill out this application form in its entirety before submission. If this is a paper application, please return it to your hospital social worker or Nurse Navigator. If approved, you will receive notification from Chemocharity. Because Chemocharity is a small, family-run organization with limited financial resources, we are unable to approve all requests. However, we will do our best to help in whatever capacity we are able. Financial assistance provided by Chemocharity may vary by circumstance and need, and may come in the form of gift cards or direct payment to creditors on your behalf.
Personal Information

Please fill out this section completely.
Your Name*

First NameLast Name
Are you requesting financial assistance for yourself or on someone’s behalf?*

For MyselfFor Another Individual
Name of Patient*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Your Date of Birth*

MonthDayYear
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Gender*

MaleFemale
Have you applied for financial aid from Chemocharity before?*

YesNo
If you have, how much did you receive? *
Email Address*
Phone Number*

Area CodePhone Number
Preferred Method of Contact*

PhoneTextEmail
Facebook Page/CaringBridge
Marital Status

SingleMarriedCohabitatingWidowedDivorcedSeparated
To which racial or ethnic group do you most identify?

American Indian or Alaskan NativeAsian or Pacific IslanderBlack, not of Hispanic originHispanicWhite, not of Hispanic originBi-racialOther
Diagnosis*
Date of diagnosis*

MonthDayYear
Date
Overseeing Doctor*
Doctor’s Name
At which hospital are you currently being treated?*
Who referred you to Chemocharity?
Tell us a little about yourself and your story.*
General Financial Information

Fill out the corresponding sections that best describes your situation.
What is the approximate total of your monthly expenses (rent, food, transportation, medication, etc.)?*
Do you receive financial assistance from any other source(s), (support, sponsorship, gofundme, etc)?*

YesNo
What is the total amount of financial assistance you have received to date?*
Are you currently employed?*

YesNo
If yes,
Other Circumstances
In the Space below (or typed on a separate page, or in an email), please describe any other reasons or circumstances (past, present, or future) that you feel increase your qualification and/or need for financial assistance from Chemocharity (e.g., family circumstances, other hardships, or other responsibilities; etc.). You may also use the space below to clarify any answers or remarks on this form.
Reason or Circumstance:
Consent Form
For Chemocharity to evaluate and process the applicant’s request for financial assistance, Chemocharity is required to verify certain information of the applicant as set forth in this consent form. If, after verification, Chemocharity determines that any information provided is not fully complete or accurate, Chemocharity reserves the right to rescind or alter any offer of financial assistance. Carefully read this consent form, complete each section, and sign/date where indicated at the end.
Signatures
Checking the boxes above and signing your name on this consent form authorizes Chemocharity to use the information provided. All forms sent to Chemocharity will be held in complete confidence during internal processing unless agreed upon above. I certify that the information provided is accurate and complete to the best of my knowledge.
Signature

Clear
Date*

MonthDayYear
Should be Empty:

Application for Financial Aid

What We Do...

How It Works...

Personal Information

General Financial Information

Signatures