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Patient Information

Who referred you to our Foundation?

Patient Name*

First Last

What is the patient's biological sex?*

Male

Female

Patient's Age*

Please enter a number from 0 to 120.

Patient's Date of Birth*

Is the patient a minor? If so, who is the patient's parent or guardian?

First Last

Contact Email*

Contact Phone Number*

Required Format: (###) ###-####

Contact Address*

Street Address Address Line 2 City State ZIP Code

How many individuals live in the household?*

Please enter a number from 1 to 50.

How many dependents are there?*

Please only count dependents under 18 years of age.

Please enter a number from 0 to 50.

Are you currently employed?*

Yes

Is your spouse or significant other currently employed?*

Yes

N/A

TOTAL Monthly Household Income*

Includes spouse, additional family, social security, disability, child support, etc.

Have you received previous support from our Foundation?*

Yes

Which year did you last receive assistance?

Which month did you last receive assistance?

Have you received assistance from other organizations?*

Yes

Which year did you last receive assistance for another organization?

Which month did you last received assistance from another organization?

What was the dollar amount you received?

Physician, Treatment & Insurance Information

Date of Last Appointment*

Date of Next Appointment*

Oncologist's Name*

First Last

Name of Hospital*

Name of Social Worker*

Social Worker Phone Number*

Required Format: (###) ###-####

Primary Cancer Type*

Stage of Primary Cancer Type*

Is the patient in active treatment?*

"Active" treatment is ongoing or has occurred in the past 12 months.

Yes

What types of active treatment has the patient undergone?

Chemotherapy

Radiation

Surgery

Do you have health insurance?*

Yes

Insurance Company

Financial Assistance and Documentation

Which item(s) are you applying for assistance with?*

For asterisked items, application must be accompanied by copies of the actual bill(s) including account number and billing mailing address to be considered. Mortgage requests must include current payment information with account number and payment stub. Rent requests must include copy of lease. All incomplete applications or applications with missing documentation will be returned. Payment for all the above is made directly to the provider, not the patient or family.

Utilities*

Mortgage*

Rent*

Gasoline Assistance

Food Assistance

Other*

Upload Required Document(s)

Drop files here or

Max. file size: 50 MB.

Application Privacy Statement & Verification Permission

The Stephen A. Comunale, Jr. Family Cancer Foundation protects the privacy of our applicants/patients and ensures the confidentiality of information regarding your medical history. Your medical history will only be shared with the Distribution Committee of the Stephen A. Comunale, Jr. Family Cancer Foundation, its agents and any references supplied by you in the application including, but not limited to the Stephen A. Comunale, Jr. Family Cancer Foundation staff, physicians and other assisting agencies. Due to the fact that the Stephen A. Comunale, Jr. Family Cancer Foundation is a cancer related organization, your creditors may become aware of the fact that you are a cancer survivor. By signing, applicant gives permission to the Stephen A. Comunale, Jr. Family Cancer Foundation for verification of all information provided in this application including any bills and personal medical/hospital statement.

Name of Patient or Legally Authorized Representative*

First Last

Description of Legally Authorized Representative's Authority

Today's Date

Share Your Story

In your own words, please tell us your story including diagnosis and treatment. This is your opportunity to tell the human side of your cancer jouney and the challenges it has caused you and your family.*

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Apply for Assistance

Patient Information

Physician, Treatment & Insurance Information

Financial Assistance and Documentation

Application Privacy Statement & Verification Permission

Share Your Story