PATH Application
ALL sections must be completed to be reviewed.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
*
example@example.com
Marital Status
Please Select
Single
Married
Separated
Divorced
Widowed
Birthdate
/
Month
/
Day
Year
Date
School (currently enrolled)?
No
Yes
School name (if applicable)
Type of lupus
SLE
Cutaneous lupus
Discoid lupus
Lupus nephritis
Drug-induced lupus
Diagnosis date
-
Month
-
Day
Year
Date
Insurance
Please Select
Private
Medicare
Medicaid
None
Are you receiving SSDI?
No
Yes
Employment status
Please Select
Full-time
Part-time
Unemployed
Student
Monthly household income
Number of household dependents
Statement of Need
Please describe the service of item that you are requesting AND provide a copy of any invoices if applicable.
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Physician Information
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office
Please enter a valid phone number.
Format: (000) 000-0000.
Fax
Please enter a valid phone number.
Format: (000) 000-0000.
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I hereby authorize the exchange of my medical information and any other pertinent information directly or indirectly related to my lupus condition between the Lupus Foundation of America, Texas Gulf Coast Chapter, Inc. and______________________________________________________________________________________ (physician/hospital/clinic/pharmacy/insurance provider).
Date
-
Month
-
Day
Year
Date
Parent/Guardian signature (if patient is under the age of 18)
Relationship to patient (if under 18)
Signature
Date
-
Month
-
Day
Year
Date
Please upload: proof of income (recent bank statement), additional income/benefits (SSDI, SSI, etc.), and a signed medical release from diagnosing physician.
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