CURRENT: Application for Medical Stipend for Cancer Treatment/Financial Hardship v2

Application for Medical Stipend for Cancer Treatment/Financial Hardship
Recipient's Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Recipient's Date of Birth*

MonthDayYear
Recipient's Address*

Street Address

Street Address Line 2

City

Zip Code
City*

Street Address

Street Address Line 2

City

Zip Code
State*

Street Address

Street Address Line 2

CityState

Zip Code
Zip Code*

Street Address

Street Address Line 2

City

Zip Code
County*

Street Address

Street Address Line 2

City

County
Number of people in family/household*
Household Annual Income*
Date of Diagnosis*

MonthDayYear
Age at Diagnosis*
Type of Cancer*
Ethnicity*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoWhiteOtherPrefer not to answer
How would you describe your current employment status?*

Employed full-timeEmployed part-timeSelf-employedUnemployedStudentOtherPrefer not to answer
Do you have any dependents who rely on your financial support?*

Yes, I have children who rely on my supportYes, I have family members who rely on my supportNo, I do not have dependentsOther
Anticipated Use of Funds (select all that apply)*

MedicalBasic NeedsChildcareTransportationOther
Stage of Diagnosis*

DCIS/Stage 0Stage 1Stage 2Stage 3Stage 4
Type of Breast Cancer*

Ductal Carcinoma in Situ (DCIS)Lobular Carcinoma in Situ (LCIS)Invasive Ductal Carcinoma (IDC)Invasive Lobular Carcinoma (ILC)
Subtype of Breast Cancer*

Hormone Receptor-positive (ER+/PR+)HER2-positive, Hormone Receptor-negativeTriple-negativeTriple-positive (HER2-positive, ER+/PR+)InflammatoryOther
What is your primary source of health insurance coverage?*

Employer-sponsored health insurancePrivate health insuranceMedicaidMedicareUninsuredOther
What hospital or healthcare system are you currently receiving treatment through?*
How did you hear about Thriving Beyond Breast Cancer?

Healthcare provider referralOnline searchSocial MediaWord of mouth (friend/family)Other
Please explain how you plan to use the stipend funds.*

Below is a list of statements that other people with breast cancer have said are important. Please mark one bubble per line to indicate your response as it applies to the past 7 days.*

	Not at all	A little bit	Somewhat	Quite a bit	Very much
I know that I have enough money in savings, retirement, or assets to cover the costs of my treatment
My out-of-pocket medical expenses are more than I thought they would be
I worry about the financial problems I will have in the future as a result of my illness or treatment
I feel I have no choice about the amount of money I spend on care
I am frustrated that I cannot work or contribute as much as I usually do
I am satisfied with my current financial situation
I am able to meet my monthly expenses
I feel financially stressed
I am concerned about keeping my job and income, including paid work at home
My cancer or treatment has reduced my satisfaction with my present financial situation
I feel in control of my financial situation
My illness has been a financial hardship to my family and me

Thriving Beyond Breast Cancer requires the following 3 supporting documents to process and approve applications.

To complete your application, kindly attach the following proof of diagnosis and financial need:
1.) Medical Record: Documentation that includes your diagnosis, treatment plan, and any ongoing medical care.*

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2.) Letter of Recommendation: A letter from your primary healthcare provider or oncologist endorsing your application and verifying that the stipend is essential for your continued treatment.*

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3.) Financial Statement: Qualifying documents may include: W-2 forms, Recent pay stubs, IRS Form 1099, Employer attestation, Social Security statement*

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Note: Your application will not be considered if supporting documentation is not provided.
Signature of Applicant:

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Date Signed:

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Date
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Application for Medical Stipend for Cancer Treatment/Financial Hardship

Thriving Beyond Breast Cancer requires the following 3 supporting documents to process and approve applications.