Application Step 1 of 12 8% Finding financial support can be difficult, but we’re here to help. Throughout this application, we’ll ask about your cancer experience and household expenses. Please answer as accurately and completely as possible. This allows us to support you as best as possible. If you need a break, use the “Save and Continue Later” button located at the bottom of the screen. Your application will be saved for 30 days. After 30 days, please start a new application. To determine if you are eligible for Family Reach’s services, Family Reach will obtain information about the patient’s health condition and treatment plan, as well as your family’s finances, living situation, and personal expenses. Family Reach is not a healthcare provider, insurer, clearinghouse, or a business associate of any healthcare organization. As such, none of the information that you provide — or that others provide on your behalf — to Family Reach is subject to the Health Insurance Portability and Accountability Act (HIPAA). It is the aim and intent of Family Reach to utilize the information that you provide — or that others provide on your behalf — to determine if you are eligible for Family Reach’s services. To do that, Family Reach may need to share information about you or your family with third parties or obtain additional information about you or your family from third parties. You or others acting on your behalf may provide Family Reach with information in electronic form. Information that is provided to Family Reach in electronic form via Family Reach’s application is maintained on Family Reach’s behalf by Salesforce.com. Information explaining how Salesforce.com maintains and safeguards that information, can be found at: Salesforce Services Trust Documentation. Your privacy is important to us: Your responses will be kept confidential and used to deliver our programs. Family Reach may share overall application data to build awareness of the financial impact of cancer, but your individual responses will never be shown and all applicants will remain anonymous. Before getting started, let’s confirm eligibility. To be considered for support through from Family Reach, patients must: Have a cancer diagnosis Be in active cancer treatment* Be receiving treatment in the US or a US territory Have a healthcare professional who can confirm their diagnosis *Treatment includes any surgery, radiation, medication, or other therapies to cure, reduce, or stop the progression of the cancer Do you or the patient you are applying for meet the above criteria?*Choose OneYes, I meet all requirementsNo, I do not meet requirementsPlease tell us what cancer diagnosis you are applying for here:*Choose OneCervicalMultiple myelomaOther pediatric/young adultOther adultWhat services are you applying for today?Resource Navigation*Not AvailableOur Resource Navigators will provide recommendations specific to your family’s financial situation, cancer diagnosis, and more.Financial Assistance*Not AvailableWhen funds are available, we offer grants to help cover non-medical expenses, including mortgage/rent payments, utility bills, groceries, and transportation. Initial InformationHiddenDate of Inquiry MM slash DD slash YYYY Applicant Name* Applicant Email* Applicant Phone Number*Preferred Language*Choose OneAmerican Sign LanguageArabicChinese (Cantonese)Chinese (Mandarin)CroatianDanishDutchEnglishFinnishFrenchGermanGujaratiHindiItalianJapaneseKoreanMacedonianNorwegianPortuguese (Brazil)RussianSpanishSwahiliSwedishTagalogThaiUrduOtherAge of Patient*Name of Hospital/Treatment center* What is the applicant's relationship to the patient?*Choose OneSelfMotherFatherSpouseDaughterSonOtherSocial Worker/Healthcare ProfessionalIf Other, What is Applicant's relationship to Patient?* How did you hear about Family Reach?*Choose OneCervivorFoundation for Women’s CancerLeukemia/Lymphoma SocietyAmerican Cancer SocietyAnthony Rizzo FoundationCancer CareDream FoundationFamily memberFamily Reach Financial GuidebookFamily Reach networkFamily Reach Sessions SeriesFriendGrytInternet searchLiFT Partner CaseLiving Beyond Breast CancerLUNGevityNewspaper/MagazineOther cancer foundationPAN FoundationPartner Hospital CasePatient resource guidePodcast/RadioPrint AdReferred by hospital social worker or other providerSocial MediaTelevisionTriage CancerOtherHiddenWhat is your relationship to the Person with Cancer?Choose OneSelfMotherFatherSpouseDaughterSonOtherSocial Worker/Healthcare ProfessionalAre you the best person in the patient’s family to contact regarding this inquiry?*Choose OneYesNoName of Person in Family to Discuss Inquiry* Relationship to Patient*Choose OneSelfMotherFatherSpouseDaughterSonOtherSocial Worker/Healthcare ProfessionalIf Other, What is your Relationship?* Email of Family Contact* Phone Number of Family Contact* Patient Demographic InformationDate of Birth* MM slash DD slash YYYY Patient's Full Name* Gender*Choose OneFemaleMaleTransgender womanTransgender manGender queerNon-binaryPrefer not to answerRace and Ethnicity*If the patient identifies with multiple races, please select all that apply. Use Click while pressing the Command key for Mac. For Windows, Click while pressing Ctrl to select multiple values. Black or African AmericanWhiteHispanic/LatinxPacific IslanderAmerican Indian and Alaska NativeOtherUnknownAsianHiddenEthnicityHispanic or LatinoNon-Hispanic or not-LatinoHometown City* Home State or Territory*Choose OneAK ALASKAAL ALABAMAAR ARKANSASAS AMERICAN SAMOAAZ ARIZONACA CALIFORNIACO COLORADOCT CONNECTICUTDC DISTRICT OF COLUMBIADE DELAWAREFL FLORIDAGA GEORGIAGU GUAMHI HAWAIIIA IOWAID IDAHOIL ILLINOISIN INDIANAKS KANSASKY KENTUCKYLA LOUISIANAMA MASSACHUSETTSMD MARYLANDME MAINEMI MICHIGANMN MINNESOTAMO MISSOURIMP NORTHERN MARIANA ISLANDSMS MISSISSIPPIMT MONTANANC NORTH CAROLINAND NORTH DAKOTANE NEBRASKANH NEW HAMPSHIRENJ NEW JERSEYNM NEW MEXICONV NEVADANY NEW YORKOH OHIOOK OKLAHOMAOR OREGONPA PENNSYLVANIAPR PUERTO RICORI RHODE ISLANDSC SOUTH CAROLINASD SOUTH DAKOTATN TENNESSEETX TEXASUT UTAHVA VIRGINIAVI U.S. VIRGIN ISLANDSVT VERMONTWA WASHINGTONWI WISCONSINWV WEST VIRGINIAWY WYOMINGAre there children under the age of 18 in the household?*Choose OneNoYesHow many people are in the patient's household?*Choose One1234567891010+Is this a single parent household?*Choose OneNoYesPlease provide more info about the household including who lives there and who contributes to the household income.*Type of Insurance*Self pay (no insurance)MedicaidMedicare onlyMedicare advantageMedicare plus supplementalACACommercial coverageTricareOther Please provide the following Social Worker InformationFull Name of Social Worker or Healthcare Professional* Title Email of SW/HCP Phone Number of SW/HCP*Extension of SW/HCP Please provide the following information about the patient's diagnosisIs this a Relapse?*Choose OneNoYesSelect Month of Initial Diagnosis*Choose One1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberEnter the Year of Initial Diagnosis*Please enter a number from 1950 to 2023.Select Month of Relapse*Choose One1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberEnter the Year of Relapse*Please enter a number from 1950 to 2023.HiddenCancer GroupPediatricYoung AdultAdultAdult and PediatricsPrimary Cancer Type*Choose OneBrainBladderBreastBreast Triple NegativeBurkitt LymphomaColonEndometrialEwing's SarcomaGastricHepatoblastomaKaposi SarcomaHodgkin LymphomaKidneyLeukemiaLeukemia - ALLLeukemia - AMLLeukemia - CLLLeukemia - CMLLeukemia - OtherLiverLungMelanomaMouthNeuroblastomaNon-Hodgkin LymphomaOsteosarcomaOvarianPancreaticProstateRectalRetinoblastomaRhabdomyosarcomaSarcoma - OtherTesticularThyroidUterineWilms TumorOther Pediatric/Young AdultOther AdultPan-TumorTumor Stage*Choose OneIIIIIIIVNot ApplicablePhase of Treatment*Choose OneOn TreatmentMonitoring and Follow-UpOff Treatment/Full RemissionPatient is deceased Family Income InformationFor up to two people who contributed to the patient’s household income what is their employment status:Have you used Savings in the Last 3 Months?*Choose OneYesNoDo not have a savings accountHas your household experienced a loss of income due to Covid-19?*Choose OneYesNoDoes your household receive or is applying for long-term disability benefits, such as Social Security Disability Income (SSDI) or Supplemental Security Income (SSI)?*Choose OneYesNoWhat was the patient's annual household income last calendar year before taxes?*Choose One$0-$9,999$10,000-$19,999$20,000-$29,999$30,000-$39,999$40,000-$49,999$50,000-$59,999$60,000-$69,999$70,000-$79,999$80,000-$89,999$90,000-$99,999$100,000 +Which of the following best represents how much income your household has lost since treatment began?*Choose OneNo household incomeSome household incomeHalf of the household incomeMost of the household incomeAll of the household incomeHow many people contributed to this household income?*Choose One012What is the current employment status of person 1?*Choose OneEmployed Full time (self employed or otherwise)Part time (self employed or otherwise)RetiredNot WorkingHiddenHas person 1’s employment status changed due to the COVID-19 pandemic?Choose OneYesNoCancer treatment can often limit a patient or caregiver’s ability to work or be employed. Over the past 3 months, how often was person 1 NOT ABLE to work or be employed due to disability, illness, injury, or mental/emotional distress - either their own or a loved one's?*Choose OneThis person’s ability to work was not impactedThis person was not able to work SOME of the timeThis person was not able to work ABOUT HALF of the timeThis person was not able to work MOST of the timeThis person was not able to work AT ALLNot ApplicableWhat is the current employment status of person 2?*Choose OneNot ApplicableEmployed Full time (self employed or otherwise)Part time (self employed or otherwise)RetiredNot Working/UnemployedHiddenHas person 2’s employment status changed due to the COVID-19 pandemic?Choose OneYesNoCancer treatment can often limit a patient or caregiver’s ability to work or be employed. Over the past 3 months, how often was person 2 NOT ABLE to work or be employed due to disability, illness, injury, or mental/emotional distress - either their own or a loved one's?*Choose OneThis person’s ability to work was not impactedThis person was not able to work SOME of the timeThis person was not able to work ABOUT HALF of the timeThis person was not able to work MOST of the timeThis person was not able to work AT ALLNot Applicable Financial NeedsHas your family experienced any kind of emergency or crisis in addition to (and not related to) the cancer?*Choose OneYesNoHas your family been concerned that you would not be able to pay for childcare?*Choose OneYesNoDoes your family have immediate concerns related to funeral costs?*Choose OneYesNoHas your family been concerned about the cost of your medical treatment or care?*Choose OneYesNoThis can include your insurance premium, any copayments or your deductible.Have you ever traveled 50 or more miles each way for cancer treatment?*Choose OneYesNoHas your family ever been concerned about the non-medical costs related to treatment?*Choose OneYesNoSuch as parking at the treatment center, meals at the treatment center, or temporary lodging near the treatment center? Please provide the following additional information about the patient:Do you regularly rely on public transportation?*Choose OneYesNoAre you current on your car payment and car insurance?*Choose OneYesNoHow many months behind?In the past 3 months, has there been concern that family would run out of food before getting enough money to buy more?*Choose OneYesNoAre one or more of your utilities currently at risk for shut off?*Choose OneYesNoIs your phone at risk of being shut-off?*Choose OneYesNo Please provide the following information about the patient’s housing expenses:Does the Household Currently Pay:*Choose OneNeither Rent or MortgageRentMortgageNeither - with stable housingNeither - without stable housingIf the household has a rent or mortgage, what is the monthly payment?*Is the household behind on the rent or mortgage payment?*Choose OneNoYesN/AIf the household has a monthly payment, how many months are they behind?*Is this household worried or concerned that in the next two months they may NOT have stable housing that they own, rent, or stay in as part of a household?*Choose OneYesNoHow has the family been financially impacted due to the cancer diagnosis? Is there anything else we should know for this application?*HiddenIs there anything else that we should know about this inquiry? Is this Application now Complete?*Choose OneNoYesCAPTCHA
