Patient Assistance Application

Patient Assistance Application

Must be in Clinton, Franklin, or Essex County, meet the ALICE financial guidelines, verify active treatment, and receipts to be approved.
Applicant Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Patient Information (if different from applicant)
Patients Name
Relationship to Patient
Medical Information
Type of Cancer (Optional)
Treatment Facility
Are you currently receiving active treatment?
Financial Reimbursement Request
Amount Requested (If Known)
What expenses do you need assistance with?
Brief Description of Need:
Please Upload Receipts for Reimbursement

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Please upload a note from your provider verifying active treatment

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Our organization follows the ALICE guidelines when determining financial need.

Please review the chart below to see if your household income falls within the guidelines and if you may qualify for assistance.
Please upload verification of financial need. (Page 1 & 2 of last year's 1040 Federal Tax Form)

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By signing below, I confirm that the information provided is accurate to the best of my knowledge
Name of Signer

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please note: Applications are reviewed on a monthly basis. If approved we will notify you via email.

Questions? Email NCCancerFund@gmail.com
Should be Empty:

Patient Assistance Application

Applicant Information

Patient Information (if different from applicant)

Medical Information

Financial Reimbursement Request

Please note: Applications are reviewed on a monthly basis. If approved we will notify you via email.