Patient Emergency Fund Application

Patient Emergency Fund Application

Lung Cancer Initiative (LCI) offers the Patient Emergency Fund to provide financial support for lung cancer patients to help with healthy food costs, transportation and other non-medical expenses during uncertain times.
Please enter the access code below to continue with the Patient Emergency Fund Application.

If you do not have the access code, please email Alisha Patel at apatel@lungcancerinitiative.org or call (919) 784-0410.

If you are a patient, please have your nurse navigator contact us for the access to code to fill out the application on your behalf.
Enter Access Code
Below are the guidelines to assist you with the completion of the paperwork necessary to apply for the patient emergency fund.

Applications may be sent to:

Mail: Alisha Patel

5171 Glenwood Ave, Suite 401

Raleigh, NC 27612

Email: apatel@lungcancerinitiative.org

Fax: 919-784-0416
1. All questions must be answered in order to be considered for fulfillment.
2. Applications must have the patient's signature and a signature from the healthcare facility.
3. One healthcare facility contact may refer up to 2 patients in need.
4. Once we receive applications, please allow up to 2 weeks for the application to be processed and mailed.
5. After the application is processed and approved, a check for $100 will be mailed to the patient’s address. LCI will email the healthcare provider to notify when the check has been mailed.
Patient Emergency Fund Guidelines
1. Applicants must be a resident of North Carolina.
2. Applicants must currently be in treatment for lung cancer.
3. Please submit applications by email, mail, or fax, utilizing the contact information above.
4. Stipends are available until funds are depleted. Priority will be given to patients living in the most distressed counties as indicated by NC Commerce’s County Distress Rankings and the patient’s demonstrated need.
Today's Date*

MonthDayYear
Applicant's Full Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*
Name of County
Home Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Patient's Email Address*
example@example.com
Please, specify your ethnicity.*

Hispanic/LatinoNot Hispanic/Latino
Please, specify your race. (Please check all that apply)*

Native AmericanNative Hawaiian/Other Pacific IslanderAsianWhite/CaucasianBlack or African AmericanOther
What is your total household income each year?*

Less than $10,000$10,000 to $19,999$20,000 to $29,999$30,000 to $39,999$40,000 to $49,999$50,000 to $75,000$75,000 to $100,000$100,000 or more
Are you employed?*

YesNo
If yes, do you work part-time or full-time?*

Part-timeFull-timeN/A
If no, are you on disability?*

YesNoN/A
If no, are you retired?*

YesNoN/A

Please describe your need for financial assistance at this time.*
How will you utilize the funding provided through this program?*

Treatment expenses (including co-pays, medications, insurance, etc.)Travel and lodgingChildcareUtilities and home expensesFood and groceriesOther
Please further explain, if needed.
How did you find out about this patient emergency fund program?*

Cancer Treatment CenterPrimary Care PhysicianAnother Lung Cancer PatientFriend or Family MemberOnlineOther
Healthcare Facility Information
Name of the facility where treatment will be received:*
Name of Healthcare Facility
Address of Facility*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Physician*

First NameLast NameCredentials
Name of Healthcare Facility Contact Person*

First NameLast NameCredentials
Email of Healthcare Facility Contact Person*
example@example.com
Phone Number of Healthcare Facility Contact Person*
Please enter a valid phone number.
Diagnosis of Patient*
Type(s) of Treatment Patient Will Receive*

ChemotherapyRadiationImmunotherapySurgeryOther
Is the patient currently enrolled in a clinical trial?*

YesNo
Privacy clause
Signature of Patient

Powered by Jotform SignClear
For providers completing this application on behalf of a patient: Please mark the checkbox indicating that the patient has given their consent for you to sign there instead.*

Yes, they have given their consent
Signature of Healthcare Facility Contact Person*

Powered by Jotform SignClear
Please verify that you are human:*
Should be Empty:

	Yes	No	N/A
Are you employed?
If yes, do you work part-time or full-time?
If no, are you on disability?
If no, are you retired?

Patient Emergency Fund Application

Healthcare Facility Information