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Live Life Even With Cancer

Family Support Program Application – Assistance Application

All information is confidential and used solely to determine eligibility for support.

APPLICANT INFORMATION

PATIENT INFORMATION

Date of Birth:
Month
Day
Year

HOUSEHOLD INFORMATION

ASSISTANCE REQUESTED

(Please check all that apply)

Multi choice

Hospital Social Worker / Case Manager (if applicable)

Other Sources of Assistance

Do you have any other funding or support sources (insurance, charities, family assistance, etc.)?
Yes
No
If yes, please list:

DOCUMENTS REQUIRED

Please attach copies of the following:


• Proof of diagnosis (doctor’s letter, medical summary or treatment plan)

• Recent medical bill, therapy invoice, or expense related to your request (if applicable)

• Parent/Guardian or Patient Photo ID

• Proof of income (pay stub, SSI, disability or unemployment documentation)

• Any medical or household bills related to assistance requested

CERTIFICATION & CONSENT

By signing below, I certify that all information provided is accurate and truthful to the best of my knowledge. I authorize Live Life Even With Cancer to contact the treating hospital, physician, or social worker to verify treatment status and financial need. I understand that assistance is based on available funds and demonstrated need.

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FOR OFFICE USE ONLY

Notes / Follow-Up:

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