Fifty Shades of Pain, Inc Lupus Survivor Assistance Application

Fifty Shades of Pain, Inc Assistance Application

Thank-You for reaching out to us. Please complete the application below. We will follow-up within 2 days of the request being made.
Today's Date

MonthDayYear
Date
Your Name

First NameLast Name
First and Last Name*
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Address*
Your Cell Phone #*
Your Email*
example@example.com
Diagnosis

Please provide us with information on your condition(s)
Have You Been Diagnosed with Lupus?*

YesNoWaiting on DiagnosisOther
If Other, please explain
If so what type have you been diagnosed with?
How Long have you been diagnosed with Lupus?

Less than a Year2 to 5 years5+ YearsI Can't Remember/Unknown
Purpose of Physician Verification

To ensure that we can provide accurate support and resources to individuals living with Lupus, we ask each new survivor to submit documentation confirming their diagnosis. This helps us maintain the integrity of our survivor programs and ensure that assistance reaches those who need it most. Please provide us with your Primary Doctor and your Rheumatologist information.
Primary Physician Name*
Primary Physician Address*
Primary Physician Phone Number*
Are You Seeing a Rheumatologist? If Yes, Complete Information Below.*

YesNoOther
Rheumatologist Name
Rheumatologist Address
Rheumatologist Phone Number
Employment
Are You Currently Employed?*
If so where?
Assistance Needed

Please complete the fields below.
What bills are you looking to get assistance with?*
Please describe in detail your need for this assistance. (What is the Hardship? Loss of Income? Unexpected Bill? Hospitalization?)*
Bill Verification

Please provide us with a copy of your bill or pay information below.
Please upload Copy of Bill (#1)

Cancelof
Please upload Copy of Bill (#2)

Cancelof
If You do not have a copy of the Bill, please provide All information needed to pay. (Company Name, Name as listed on the bill, account number, address, phone, amount...Any information needed to make sure the bill is paid correctly)
Additional Comments. Do you need to share anything else with us?
Confidentiality Statement

Your privacy is our priority. All medical information and documentation provided will be kept strictly confidential and used solely for verification purposes. This information will not be shared outside of our organization without your written consent.
Consent Acknowledgment

By submitting this form and my signature, I acknowledge that the documentation provided is accurate and that I authorize Fifty Shades of Pain, Inc to verify my Lupus diagnosis solely for program eligibility and support services.
Signature

Clear
Should be Empty:

Fifty Shades of Pain, Inc Assistance Application

Diagnosis

Purpose of Physician Verification

Employment

Assistance Needed

Bill Verification

Confidentiality Statement