CSS Patient Assistance Application
For CSS clients who are unable to pay our published rate for services.
Name
*
First Name
Last Name
Email
*
example@example.com
Please select your annual household income for all members of your household combined.
*
less than $50,000
$50,000-$75,000
over $75,000
How many individuals are in your household, including yourself?
*
1
2
3
4
5 or more
What is your cancer diagnosis, including staging?
*
When did you first receive your cancer diagnosis?
*
-
Month
-
Day
Year
Date
What treatments are you currently receiving (eg chemo, radiation, immunotherapy, surgery, acupuncture and /or any other complementary or adjunctive treatments)?
*
How long has it been since you completed active cancer treatment (chemo, radiation, immunotherapy, surgery). If not applicable, please answer N/A
*
How is your cancer diagnosis and/or cancer treatment currently affecting your activities of daily living?
*
Please let us know if there are other factors effecting your ability to pay $90/session, and if so, what amount are you able to pay? Please provide as much detail as possible to allow us to understand your financial situation.
*
Submit
Should be Empty: