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 Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
County
*
Please Select
Collin
Dallas
Denton
Ellis
Hunt
Johnson
Kaufman
Parker
Rockwall
Tarrant
Wise
Other
Please select the county you live in
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Language
Gender
*
Male
Female
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
*
-
Month
-
Day
Year
Date
Primary Treating Physician
*
Physician's Phone Number
*
Please enter a valid phone number.
Hospital Where You are Being Treated
HEALTH INSURANCE INFORMATION
Does the Patient Have Health Insurance?
*
Yes
No
Type of Insurance (check all that apply)
Private (including employer plans and Healthcare Marketplace)
Medicare
Medicaid
Medicare Advantage
Other
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
Is the Patient Employed?
*
Yes
No
If Employed is the Patient Able to Work During Treatment?
Yes
No
Annual Household Income
*
Number of People In Household
*
Household Occupants Under Age 18
*
Sources of Income (pick all that apply)
No Current Sources of Income
Patient's Earnings
Spouses Earnings
Social Security
Pension
Unemployment
Short/Long Term Disability
Social Security Disability
Public Assistance
Other
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.
Which of the following best describes you? (please select one)
*
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Alaskan Native
White or Caucasian
Multiracial or Biracial
A race/ethnicity not listed here
Prefer not to answer
OTHER INFORMATION
May we share your story to help us promote our organization for future fundraising purposes? Your answer WILL NOT be used in our decision to provide financial assistance.
*
Yes
No
How did you hear about us?
Referred by my treatment provider's office
Search engine
Me Squared web site
TV or newspaper story
Me Squared Brochure
A friend
Someone we've helped in the past
Other
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.
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.
Browse Files
Drag and drop files here
Choose a file
If possible add each document as a separate file.
Cancel
of
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
*
Date
*
-
Month
-
Day
Year
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.
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"
Print
Submit
Pronoun
Pronoun 2
Pre-Screened?
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