Financial Aid Application Screening Form
Patient's Name
*
First Name
Last Name
Who is completing this form?
*
Patient
Treatment provider representative
(Family member or friend)
Other
Your Name
First Name
Last Name
Your Email address (in case we have questions)
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
#1. Was the patient diagnosed with cancer in the last 6 months (or re-diagnosed with a recurrence in the previous 6 months)?
*
Yes
No
#2. Patient's County of Residence
*
Please Select
Collin
Dallas
Denton
Ellis
Hunt
Johnson
Kaufman
Parker
Rockwall
Tarrant
Wise
Other
Me Squared can only provide assistance paying cancer related treatment costs. Unfortunately, we cannot assist with rent, utilities, car payments, etc.
#3. Does the patient need assistance with cancer treatment costs?
*
Yes
No
#4. Current annual household Income
*
Current income from all sources.
#5. Number of people in household
*
#6. Is the patient working with one of the following at their treatment provider: Case Manager, Nurse Navigation, Financial Aid representative, or someone else who we can work with to get information on the patient's share of treatment costs (estimates or actual costs)?
*
Yes
No
#7. Is patient age 18 years or older?
Yes
No
Next Steps:
If the patient meets our screening criteria, when you press Submit you will be taken to our full application form.
Submit
250% Income Level
Response 1
Value = 1 if recently diagnosed
Response 2
Value = 1 if in service area
Response 3
Value = 1 if needs help with medical bills
Response 4
Value = 1 if has a hospital contact for us.
Response 5
Value = 1 if below 250%
Response 6
Value = 1 if patient age is 18 or older
Sum of Conditions
Should be Empty: