Apply Online | Stephen A. Comunale, Jr. Family Cancer Foundation

Patient Information

Referred to the Organization by:

Patient Name*

First Last

What is your biological sex?*

Male
Female

Age (in years):*

Please enter a number from 0 to 120.

Date of Birth:*

Contact Email:*

Contact Phone Number:*

Contact Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number in household:*

Please enter a number from 1 to 50.

Number of dependents (under 18):*

Please enter a number from 0 to 50.

If patient is a minor, name of parent or guardian:

First Last

Currently employed?*

Yes
No

Spouse currently employed?*

Yes
No
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
No

Please indicate the year in which you last received assistance:

Please indicate the month in which you last received assistance:

Have you received assistance from other organizations?*

Yes
No

Please indicate the year in which you last received assistance:

Please indicate the month in which you last received assistance:

Please indicate the amount you received:

Physician, Treatment, & Insurance Information

Date of Last Appointment:*

Date of Next Appointment:*

Oncologist's Name*

First Last

Hospital Information — Name of Hospital:*

Hospital Information - Name of Social Worker:*

Social Worker Phone Number:*

Primary Cancer Type:*

Stage of primary cancer type:*

Are you in active treatment (treatment within the last year)?*

Yes
No

If yes, please check all that apply:

Chemotherapy
Radiation
Surgery

Do you have health insurance?*

Yes
No

If yes, name of insurance company:

Financial Assistance and Documentation

Please check item(s) you are 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*

File Upload

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

E-Signature of Patient or legally authorized representative:*

Description of legally authorized representative's authority (if applicable):

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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