Stardust-Sharsheret Oncofertility Grant Application
Egg Freezing & IVF Financial Assistance for Cancer Patients
1. Applicant Information
Full Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
City & State of Current Residence
*
U.S. Citizenship / Immigration Status
*
Please Select
U.S. Citizen
Lawful Permanent Resident
Visa Holder
Other
Relationship / Household Status
*
Please Select
Single
Married / Civil Union
Domestic Partnership
Legally Separated
Divorced
Other
If 'Other' Relationship / Household Status, please specify
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Mailing Address
*
Submission Date
-
Month
-
Day
Year
Date
2. Financial Information
Household Adjusted Gross Income - Tax Year 1
*
Household Adjusted Gross Income - Tax Year 2
*
Tax Year 1
*
Tax Year 2
*
Estimated total out-of-pocket cost for fertility preservation
3. Fertility Care and Insurance
Reproductive Endocrinologist / Physician Name
Fertility Clinic or Practice Name
Clinic Mailing Address
Do you currently carry medical or fertility insurance?
*
Please Select
Yes
No
Not Sure
Insurance Carrier Name
Member / Policy Number
Group Number
Has your clinic submitted a prior authorization or claim to your insurance carrier?
*
Please Select
Yes
No
In Progress
Haven't Started Yet
If yes or in progress, summarize the pre-authorization outcome or status
4. Oncology and Treatment Details
Treating Oncologist's Full Name
*
First Name
Middle Name
Last Name
Oncology Practice / Hospital Affiliation
*
Cancer Type & Stage
*
Date of Cancer Diagnosis
*
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Month
-
Day
Year
Date
Planned or Current Cancer Treatment
*
Anticipated Start Date of Cancer Treatment
*
-
Month
-
Day
Year
Date
Any Additional Medical Context the Review Committee Should Be Aware Of
5. Application Narrative and Referral Source
How did you learn about this grant program?
Please share anything else that may support your application
6. Permission, Certification, and Signature
Permission to contact for follow-up or impact reporting
*
Please Select
Yes
No
I have read and agree to the Certification, Authorization & Release of Information terms above
*
I agree
Applicant Full Legal Name (print)
*
Signature Date
*
-
Month
-
Day
Year
Date
Applicant Signature
*
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