We Stand Together, Inc. Financial Assistance Application
FINANCIAL ASSISTANCE PROGRAM ELIGIBILITY SCREENING & IN TAKE FORM
APPLICANT INFORMATION
Name
*
Legal First Name
Middle Initial
Legal Last Name
Click here to enter a date.
*
/
Month
/
Day
Year
Date
Gender
*
Male
Female
Other
Place of Birth (City)
*
City
Place of Birth (State)
*
State
Place of Birth (Country)
*
Country
Diagnosis Type
*
Year of diagnosis
*
Treating clinic
*
Treating Physician
*
Treating Physician Contact Number
*
Marital Status
*
Please Select
Choose an option
Single
Married
Separated
Divorced
Widowed
Domestic Partnership
Race
*
Please Select
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian
Other Pacific Islander
Multiracial
Other
Are you Hispanic or Latino?
*
Yes
No
Type of Living Expense Assistance Needed
*
Groceries
Utilities
Rent/Mortgage
Gas
Transportation
Childcare
Co-Pay/Co-Insurance
Phone Bill
Medical Bill
Housekeeping
Current Living Street Address
*
City
*
State
*
Zip
*
County of Residence (ie. Monroe, Miami-Dade, Broward, Palm Beach, etc.)
*
Preferred Phone Number
*
Other Phone Number
Work Status
*
Employed
Self-employed
Unemployed
Disabled
Retired
Part Time Student
Full time Student
Veteran
Are you currently in active treatment
*
Yes
No
Do you have proof of unemployment
*
Yes
No
Employer Name
Employer Phone
Employer Email
example@example.com
Applicant Email Address
*
example@example.com
How did you hear about our program? Referral Source
*
PARENT/LEGAL GUARDIAN (IF MINOR)
Legal Custody
Mother
Father
Both Other
Legal Guardian Name
First Name
Last Name
Legal Guardian Date of Birth
/
Month
/
Day
Year
Date
Relationship to Patient
Legal Guardian Address
Address / Apt
Street Address Line 2
City, State, Zip
State / Province
Postal / Zip Code
Legal Guardian Mobile
Legal Guardian Email Address
example@example.com
EMERGENCY CONTACT INFORMATION
*
First and Last Name
Relationship to Applicant
*
Mobile Phone
*
Email Address
example@example.com
Applicants must submit the required supporting documents:
Current bill statement that reflect assistance requested, a physician statement on letterhead from the treating physician, proof of unemployment (if unemployed). In order to be considered for assistance all documents must be submitted and must be current. Bills submitted cannot be older than 30 days from date of application. Physician statement cannot be older than 3 months from date of application.
1. Upload Physician statement on letterhead reflecting diagnosis. Statements should not be older than 3 months. Statements must include the following information: (a) Diagnosis type (b) Year of diagnosis (c) Duration of treatment (d) Name of treating physician (e) Email and phone contact for treating physician, case manager, and or social worker
*
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of
2. Upload outstanding medical bill(s). Medical bills submitted must be directly related to treatment. Medical bill should not be older 30 days from date of application.
*
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3. Upload any of the following bill(s) you would like to receive funding assistance for: current utility bill, current rent ledger, current mortgage statement, current car insurance statement, current car note statement, current childcare invoice/statement, current phone bill, current statement reflecting patient co-insurance responsibility. Statements/invoices/bills cannot be older than 30 days from date of application
*
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of
4. Upload Hardship letter or Proof of unemployment
*
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of
Patient (Signature)
*
Date
*
/
Month
/
Day
Year
Date
Parent/Legal Guardian (Signature)
Date
/
Month
/
Day
Year
Date
Submit
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