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*

MonthDayYear

Patient's Name*

First NameLast NameSuffix

Patient's Date of Birth*

MonthDayYear

Patient's Address*

Street Address

Street Address Line 2

CityState

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 NameLast Name

Title*

Member of Team completing form*

First NameLast Name

Title*

Member of Team E-mail*

Facility Address*

Street Address

Street Address Line 2

CityState

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.