We Stand Together, Inc. Financial Assistance Application

We Stand Together, Inc. Financial Assistance Application
FINANCIAL ASSISTANCE PROGRAM ELIGIBILITY SCREENING & IN TAKE FORM
APPLICANT INFORMATION
Name

Legal First NameMiddle InitialLegal Last Name
Click here to enter a date.

MonthDayYear
Date
Gender

Other
Place of Birth (City)
City
Place of Birth (State)
State
Place of Birth (Country)
Country
Diagnosis Type
Year of diagnosis
Treating clinic
Treating Physician
Treating Physician Contact Number
Marital Status
Race
Are you Hispanic or Latino?
Type of Living Expense Assistance Needed
Current Living Street Address
City
State
Zip
County of Residence (ie. Monroe, Miami-Dade, Broward, Palm Beach, etc.)
Preferred Phone Number
Format: (000) 000-0000.
Other Phone Number
Format: (000) 000-0000.
Work Status
Are you currently in active treatment
Do you have proof of unemployment
Employer Name
Employer Phone
Format: (000) 000-0000.
Employer Email
example@example.com
Applicant Email Address
example@example.com
How did you hear about our program? Referral Source
PARENT/LEGAL GUARDIAN (IF MINOR)
Legal Guardian Name

First NameLast Name
Legal Guardian Date of Birth

MonthDayYear
Date
Relationship to Patient
Legal Guardian Address

Address / Apt

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Legal Guardian Mobile
Format: (000) 000-0000.
Legal Guardian Email Address
example@example.com
EMERGENCY CONTACT INFORMATION
First and Last Name
Relationship to Applicant
Mobile Phone
Format: (000) 000-0000.
Email Address
example@example.com
Applicants must submit the required supporting documents:

Current bill statement that reflect assistance requested, a physician statement on letterhead from the treating physician, proof of unemployment (if unemployed). In order to be considered for assistance all documents must be submitted and must be current. Bills submitted cannot be older than 30 days from date of application. Physician statement cannot be older than 3 months from date of application.
1. Upload Physician statement on letterhead reflecting diagnosis. Statements should not be older than 3 months. Statements must include the following information: (a) Diagnosis type (b) Year of diagnosis (c) Duration of treatment (d) Name of treating physician (e) Email and phone contact for treating physician, case manager, and or social worker

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2. Upload outstanding medical bill(s). Medical bills submitted must be directly related to treatment. Medical bill should not be older 30 days from date of application.

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3. Upload any of the following bill(s) you would like to receive funding assistance for: current utility bill, current rent ledger, current mortgage statement, current car insurance statement, current car note statement, current childcare invoice/statement, current phone bill, current statement reflecting patient co-insurance responsibility. Statements/invoices/bills cannot be older than 30 days from date of application

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4. Upload Hardship letter or Proof of unemployment

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Patient (Signature)
Date

MonthDayYear
Date
Parent/Legal Guardian (Signature)
Date

MonthDayYear
Date
Should be Empty:

We Stand Together, Inc. Financial Assistance Application

FINANCIAL ASSISTANCE PROGRAM ELIGIBILITY SCREENING & IN TAKE FORM

APPLICANT INFORMATION

Applicants must submit the required supporting documents: