Application for Assistance Form

Name of Patient*

First NameLast Name

Preferred Name

Optional

Date of Birth*

MonthDayYear

Social Security Number

Sex assigned at birth*

Ethnicity*

Home Phone:

Cell Phone

E-mail

example@example.com

Address:*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

County of Residence*

# of People in Household*

Employer

Diagnosis-Cancer Type*

If Other, please specify:

Date of Diagnosis

Date

Treatment Types

Date of last treatment or surgery

Date

Physician Name(s)

Vehicle Information:
Year: Make: Model:

Yearly Household Income*

Insurance-(Choose all that apply)*

Services Requested-(Choose all that apply)*

Please briefly describe how cancer has impacted you financially:*

If you are NOT a patient at Highlands Oncology, proof of diagnosis is required. Please upload a pathology report or letter from your physician.

Application for Assistance