Incyte Cancer Care Assistance Fund (updated 6/2023)

The Incyte Cancer Care Assistance Fund for Delaware

Application for first time applicants. (Second time applicants please use Addendum Application.)

Today's Date*

Date

Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Email address*

example@example.com

Date of Birth*

Date

Refered by*

Hospital/Cancer Center where applicant is being treated:*

Treating Physician's name and phone number:*

CANCER DIAGNOSIS (type, stage if known):*

Date of Diagnosis*

Is this your initial diagnosis?*

YesNo

Briefly describe surgery related to your cancer, including date performed or expected*

Briefly describe treatment plan (chemotherapy, radiation, etc.)*

Name of Primary Insurance Company/Insurer:*

Name of Secondary Insurance, if applicable:

Are you the insured?*

YesNo

If dependent, name and relationship of the insured:

Briefly describe your financial situation and how your cancer diagnosis and treatment have caused you financial hardship (give as much specific information as possible, including current and future employment situation). *

Please describe the specific medical or living expenses for which you are requesting assistance*

Are you currently employed?*

YesNo

Name and address of employer:*

Total number of dependents in the household (including children/spouse/parents/etc.):*

Total number of working adults in the household (including children/spouse/parents/etc.):*

Combined Household Income*

	Before Diagnosis	After Diagnosis
Net Monthly Salary
Social Security
Disability (short or longterm)
Other

List all expenses you are asking for assistance with and provide legible copy of bill(s) you wish to be paid. Bills must show the payment coupon, your total name and address, total due, and total name and address of payee. Screen shot of a current bill in not acceptable, it must be an invoice.

Type a question*

	Provider/ Company	Amount Due	Date Due
Rent/Mortgage
Electric
Gas/Oil
Phone/Internet
Cell Phone
Medical
Medical
Medical
Medical
Other
Other
Other

Please upload all bills here. PDF, JPEG and PNG are accepted. Bills must show the payment coupon, your name and address, total due, and name & address of payee. Screen shot of a current bill in not acceptable, it must be an invoice.*

CERTIFICATION OF INFORMATION PROVIDED

I hereby certify, under penalty of perjury, that the information set forth on this applica- tion concerning my income, liabilities and insurance provider is true and accurate and that the expenses for which I have requested financial assistance impose a financial hardship for me. Further, I have been diagnosed with cancer, I am undergoing treat- ment for, or I have recently undergone treatment for cancer, and I do not have adequate resources or income to pay for the expenses. I reside in Delaware, and I am a citizen of the United States. I understand that if any of the information set forth above is false, that my application will be null and void. By signing below, I hereby grant and give permission for representatives of Cancer Sup- port Community Delaware to contact my physician(s) and/or medical team member(s) as needed.

Signature of applicant*

Clear

Cancer Support Community Delaware 4810 Lancaster Pike Wilmington, DE 19807 Phone: (302) 995-2850 Fax: (302)995-0834 npickles@csede.org

MEDICAL INFORMATION

INSURANCE INFORMATION

PERSONAL STATEMENT

FINANCIAL/INCOME INFORMATION

EXPENSES