Loving Arms Cancer Outreach: Application for Assistance (GEORGIA ONLY)

Application for Patient Financial Assistance

ONLY APPLY IF YOU RESIDE WITHIN ONE OF THE FOLLOWING GA COUNTIES: BARTOW, CARROLL, CHEROKEE, COBB, DOUGLAS, PAULDING, PICKENS.
PLEASE COMPLETE ALL SECTIONS

Have Questions? Contact 770-693-1812 or info@lovingarms.support
Section 1: Patient Information
Date of Application*

MonthDayYear
Date
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Last 4 of SS#
For record keeping only
Sex*
Address*

Street Address

Street Address Line 2

CityState (GA)

Postal / Zip Code
County of Residence*
We only assist counties listed above
Phone Number*
Please enter a valid phone number.
Select Which Type of Number Your Provided Above:*

CellphoneHome
Are you able to receive text messages to this number?*

YesNo
Email*
example@example.com
If patient is currently unable to speak on the phone or is not an English Speaker, provide contact information for a friend/family member authorized to speak on their behalf:
Name
Phone Number
Please enter a valid phone number.
Relation to Patient
Section 2 : ONCOLOGIST INFORMATION

This form will be sent to your oncologist to verify all information provided is correct.
Oncologist Name*
Please Enter Doctor's Full Name
Practice/Facility/Hospital*
Emory, Wellstar, Piedmont, Etc.
Location of Practice (if multiple)*
Kennesaw, Canton, Marietta, etc.
Practice Address*
Practice Telephone*
Practice Fax *
Please enter a valid phone number.
REFERRING PROFESSIONAL- Primary contact for this application (Social worker, Nurse Navigator, etc):
Name & Title
Practice/ Facility/ Organization
Contact Phone
Contact Email
example@example.com
Section 4: Needs Assessment – Please Provide Information If Available

This information is required for grant applications. Your answers will not disqualify you from receiving assistance. Please answer truthfully
Ethnicity:*

African AmericanAsian or Pacific IslanderHispanicNative AmericanWhiteOther
Total # of people in the home*
Any dependents? If so, list ages*
1,3,5,7, etc.
Number of Employed Adults in the Home*
18+ years of age
Marital Status*

SingleMarriedDivorcedWidowed
Employment Status:*

Full-TimePart-TimeRetiredUnemployedLeave of Absence
Your Cancer Diagnosis Has:*

Made You UNABLE TO WORKForced You To Reduce HorsNot Affected Your Job
Current Sources of Income:*

PensionSocial SecuritySSISSDIChild SupportWages/ SalaryFriends/FamilyShort Term DisabilityFood StampsTANFUnemployment BenefitsLong-Term DisabilityIn-Kind (Room & Board)Other
Total YEARLY HOUSEHOLD income (from all sources)*
Do Not Include ($)
Total YEARLY PERSONAL income (from all sources)*
Do Not Include ($)
What Type of Insurance Does the Patient Have?*

Private InsuranceMedicareMedicaidVA BenefitsUninsured
What Type of Assistance is the Patient Seeking?*

Utilities (electric, gas, water, phone)Support GroupWigs, Hats & ScarvesGroceriesUber/Lyft CardsGas CardsOther
Have you applied and/or been awarded assistance from other organizations or agencies?*

YesNo
If you answered "yes" above, please list any/all agencies you've contacted:
Section 5: PATIENT SIGNATURE
APPLICANT (PATIENT):All the information I have provided for this application is true and correct. I understand that Loving Arms Cancer Outreach Inc. offers assistance to eligible patients for treatments/products/ activity of daily living needs expressly covered by this outreach program. While Loving Arms will make every effort to grant assistance when needed, the program is limited by available resources and may be discontinued or changed at any time.
PATIENT Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
SECTION 6: ADDITIONAL INFORMATION
Is there any additional information we should know regarding applying patient?
Please tell us briefly about how you heard about Loving Arms Cancer Outreach—a client, social worker, internet search, your doctor, etc.
Referred by
Should be Empty:

Application for Patient Financial Assistance

PLEASE COMPLETE ALL SECTIONS

Section 1: Patient Information

Section 2 : ONCOLOGIST INFORMATION

Section 4: Needs Assessment – Please Provide Information If Available

Section 5: PATIENT SIGNATURE

SECTION 6: ADDITIONAL INFORMATION