How to Apply
In completing the application you will need to have the following information ready:
- Information about your diagnosis
- Insurance policy information and a photocopy of your card (front and back)
- Income information and a photocopy of your most recent taxes
- Physician / Pharmacy / Infusion Therapy addresses and telephone numbers
- Estimated monthly cost of your copayments including office visits, medications, etc.
There are four steps to completing the application
- Print the application here
- Complete the application
- Deliver the physician's verification form to your doctor. They must complete this, and mail it to us.
- Attach the required documentation and statements to the back of the application, and mail this completed packet to us.
When you complete the application, please attach the following and mail your completed application to:
Cancer Copay Relief
2275 Smith Avenue SW
Marietta, GA 30064
- A clear photocopy of your most recent insurance cards (front and back). If the information is difficult to read, please write it legibly on the photocopy
- A copy of your most recent taxes verifying all income sources.
- A written statement describing your current situation. We find that facts and figures only account for a portion of the human condition. Let us know what’s going on in your life.
Click here to access the printable application