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.Format: (000) 000-0000.
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
How would you describe your current employment status?
Do you have any dependents who rely on your financial support?
Anticipated Use of Funds (select all that apply)

Other
Stage of Diagnosis
Type of Breast Cancer
Subtype of Breast Cancer
What is your primary source of health insurance coverage?

Other
What hospital or healthcare system are you currently receiving treatment through?
How did you hear about Thriving Beyond Breast Cancer?

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.

Rows	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:
Date Signed:

MonthDayYear
Date
Note: All fields must be completed before signature field is activated.
Should be Empty:

Application for Medical Stipend for Cancer Treatment/Financial Hardship

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