Financial Aid Application

Financial Aid Application
NOTE:

Me Squared Cancer Foundation is able to provide financial assistance to newly diagnosed adult cancer patients in the DFW area for treatment related costs. These costs include medical costs, travel to/from treatment, and lodging if treatment is needed far from the patient's home. Payments are made directly to treatment providers on behalf of the patient. Unfortunately, we are unable to provide financial assistance for ordinary living expenses such as rent and utilities. APPLICATIONS MUST BE SUBMITTED ONLINE HERE. WE CANNOT ACCEPT EMAIL OR PAPER APPLICATIONS
PERSONAL INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
County *
Please select the county you live in
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Primary Language
MaleFemale
Best times to contact you with questions:
What times of day and days of work are most convenient for you?
MEDICAL INFORMATION
Type of Cancer*
Date of Diagnosis*

MonthDayYear
Date
Primary Treating Physician*
Physician's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Hospital Where You are Being Treated
HEALTH INSURANCE INFORMATION
YesNo
Private (including employer plans and Healthcare Marketplace)MedicareMedicaidMedicare AdvantageOther
Annual Deductible
Amount you have to pay before insurance starts paying
Annual Out-of-Pocket Maximum
Amount you have to pay before insurance covers 100%
INCOME INFORMATION
YesNo
YesNo
Annual Household Income*
Number of People In Household*
Household Occupants Under Age 18*
No Current Sources of IncomePatient's EarningsSpouses EarningsSocial SecurityPensionUnemploymentShort/Long Term DisabilitySocial Security DisabilityPublic AssistanceOther
FINANCIAL HARDSHIP INFORMATION
What will this money be used for and when is it needed? Will you need to travel for care?
Please describe your situation. Why is this a financial hardship and how will this grant help you?
Tell us a little bit about yourself; career, interests, family, etc.
DEMOGRAPHIC INFORMATION

Me Squared Cancer Foundation is committed to serving the needs of ALL adult newly diagnosed cancer patients in our service area regardless of their race or ethnicity. The following information is collected solely for demographic purposes to help us better serve cancer patients in our community and is NEVER used in the decision to provide aid.
Asian or Pacific IslanderBlack or African AmericanHispanic or LatinoNative American or Alaskan NativeWhite or CaucasianMultiracial or BiracialA race/ethnicity not listed herePrefer not to answer
OTHER INFORMATION
YesNo
Referred by my treatment provider's officeSearch engineMe Squared web siteTV or newspaper storyMe Squared BrochureA friendSomeone we've helped in the pastOther
We need the contact information of someone who can answer questions about your medical bills at your treatment provider's office (financial aid manager, case manager, nurse navigator, etc.) please provide contact information for that person below:
Name of facility*
Contact Name*
Contact Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Contact Email*
example@example.com
If you have copies of medical bills or diagnosis information that you think would help us, please add those files here. This is NOT required.

If possible add each document as a separate file.
Cancelof
GRANT APPLICATION WILL NOT BE REVIEWED WITHOUT A SIGNATURE

I certify that the information I have provided in this application is true and accurate. I give permission for my doctors and staff to provide information about my condition and treatment to Me Squared Cancer Foundation.
Applicant's Name
Signature*

Clear
Date*

MonthDayYear
Date
If someone other than the applicant filled this form please complete the following section
Name of person completing form
Relationship to applicant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Click "Save" if you want to save your input and continue later

You will be prompted to enter an email address. A link will be sent to that address to allow you to continue filling out the form.
Click "Print" if you want print a copy of your submission

Not Required
When you are done entering data please click "Submit"
Pronoun
Pronoun 2
Pre-Screened?
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Financial Aid Application

NOTE:

PERSONAL INFORMATION

MEDICAL INFORMATION

HEALTH INSURANCE INFORMATION

INCOME INFORMATION

FINANCIAL HARDSHIP INFORMATION

DEMOGRAPHIC INFORMATION

OTHER INFORMATION

We need the contact information of someone who can answer questions about your medical bills at your treatment provider's office (financial aid manager, case manager, nurse navigator, etc.) please provide contact information for that person below:

GRANT APPLICATION WILL NOT BE REVIEWED WITHOUT A SIGNATURE

If someone other than the applicant filled this form please complete the following section

Click "Save" if you want to save your input and continue later

Click "Print" if you want print a copy of your submission

When you are done entering data please click "Submit"

We are sorry - It appears you are not authorized to use this form. Use your browser's exit button to leave this page. For more information contact us at info@mesquaredcf.org