Today's Date (required field)

Applicant's Name (required field)

Phone Number (required field)

Your email (required field)

Street Address (required field)

City, State (required field)

County (required field)

Birthdate (required field)

To which gender identity does the applicant most identify?
FemaleMaleTransgender FemaleTransgender MaleGender Variant/Non-ConformingPrefer Not to AnswerNot Listed

If Applicant's Gender Identity is Not Listed, please state:

Please identify the ethnicity the applicant identifies with.
American IndianAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhitePrefer Not to Answer

Date of Diagnosis (required field)

Stage (required field)

Type (required field)

If unemployed, last date of employment? (optional field)

Employer (optional field)

How did you hear about the organization? (required field)

Has the applicant received assistance from other organizations? (required field) YesNo

If so, When? (optional field)

If so, Where? (optional field)

If so, Type of Assistance? (optional field)

Total household income of applicant? (required field) WeeklyMonthlyAnnualOther

Is applicant receiving any type of aid? (Check all that apply - required field)
public aidwelfarefood stampssocial securityUnemployment insuranceUnion BenefitsDisability Insurance
Other?

Monthly Expenses: (all fields are required)
Rent or Mortgage:
Food:
Utilities:
Credit cards:
Medical Insurance:
Car(s) Payment(s):
Other Monthly Expenses:

What assistance is requested from the organization? (please describe in detail) (Limit $3000/patient/year) WE DO NOT PAY MEDICAL BILLS. (required field)

Attach a copy of your first invoice you require financial assistance with form needs to be in PDF format (Required)

Attach a copy of your second invoice you require financial assistance with form needs to be in PDF format (Optional)

Attach a copy of your third invoice you require financial assistance with form needs to be in PDF format (Optional)

Attach a copy of your fourth invoice you require financial assistance form needs to be in PDF format with (Optional)

Attach a copy of your fifth invoice you require financial assistance with form needs to be in PDF format (Optional)

Attach a copy of your state issued identification card (Driver's license)

Does applicant currently have an oncology doctor? (If yes, complete below.)
YesNo
Doctor's Name:
Doctor's Email:
Doctor's Phone:

I the applicant, understand that I may be interviewed by telephone, or in person, if additional information or if clarification of this application is needed. I have answered all questions truthfully and to the best of my ability" YesNo
I the applicant consent Helping Hands Cancer Outreach to contact my Doctor to confirm diagnosis and patient status YesNo
Thank you for contacting Helping Hands Cancer Outreach. We will review your application and get back to you as soon as possible.