GHH Medical Verification

Application for

The Genevieve Memorial Breast Cancer Recovery Grant

Medical Verification

To be completed by a member of the

Patient’s Medical Team

Date of Medical Verification *

Month Day Year

Patient's Name *

First Name Last Name Suffix

Patient's Date of Birth *

Month Day Year

Patient's Address *

Street Address

Street Address Line 2

City State

Zip Code

Diagnosis (type,stage, etc.) *

Date(s) of Treatment(s) *

Month/Year

Type of Treatment(s) *

Treatment Facility *

Location

City, State

Physician Name (Provider) *

First Name Last Name

Title *

Member of Team completing form *

First Name Last Name

Title *

Member of Team E-mail *

Facility Address *

Street Address

Street Address Line 2

City State

Zip Code

Facility Phone Number *

Comments (Optional)

I affirm that all informaton is correct. I understand that Genevieve's Helping Hands, Inc. is not a health care provider, and therefore the information released is not protected by federal privacy protections.

Signature of medical verifier (please use cursor to draw signature) *

Grant Criteria

For mothers first diagnosed with breast cancer at age 40 or younger

Associated with recovery from breast cancer treatment

To be applied at mutually agreed upon dates and a location arranged by

Genevieve’s Helping Hands, Inc.

Genevieve's Helping Hands will pay for Grant location and related expenses.