Patient Application for Financial Assistance

Eligibility Requirements
Palm Beach County cancer patients (any age, any cancer) who are experiencing financial hardship while in active treatment (infusion chemotherapy, radiation, or immunotherapy.)

Your Personal Information

Your Name(Required)

First Middle Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Date of Birth

Gender

Ethnicity

Veteran

Yes

Spouse Name

First Last

Roommate or Significant Other

First Last

Children (living at home) names and ages

Pets (living at home) names and types

Household Monthly Income

Applicant Employer’s Name

Applicant Monthly Income $

Spouse/Partner Employer’s Name

Spouse/Partner Monthly Income $

All Individuals 21 years of age, or older, living with Applicant

Please provide Employer's Name and Monthly Income $

Other Income: Child Support, Alimony, Public Assistance, Social Security, Pension, Self-Employed, Business Owner

Please provide Source of Income and Monthly Income $

Bank Accounts (Savings / Checking / Money Market / CDs / IRA)

Applicant Bank Name

Balance of Last Statement $

Spouse / Partner Bank Name

Balance of Last Statement $

Assets (House / Other Real Estate / Car / Boat)

Applicant House

Please provide the Address and Value

Applicant Car(s)

Please provide the Make/Model/Value

Other

Spouse / Partner House

Please provide the Address and Value

Spouse / Partner Car(s)

Please provide the Make/Model/Value

Other

Applicant Monthly Expenses

Mortgage / Rent

Utilities

Food

Car Payment

Car Insurance

Fuel

Phone

Health Ins.

Hospital Bills

Treatments

Prescriptions

Other Medical

Loans

Credit Cards

Other

Medical Information

Type of Cancer

Diagnosis Date

Stage

Treating Physician

Physician Phone

Physician Address

Street Address City State / Province / Region ZIP / Postal Code

Do you have Health Insurance?

Yes

If so, what type of insurance?

Referral

Referred by

Organization Name:

Phone

Specify the type of assistance being requested: (Check all that apply)

Explanation of Need

Include a detailed explanation of the circumstances which require you to request financial assistance.

Should your application be approved, please list in order of priority those bills you wish CAHH to pay. Checks cannot be made payable to the applicant.