Application Instructions and Checklist

Thank you for sharing with us. We’re glad you’re giving us an opportunity to help you and your loved ones in your diagnosis.

We determine eligibility based on current need and funding available. You will be notified as soon as possible to the status of your application.

Once you’ve been approved, we’ll determine the amount and nature of your grant. Please send inquiries pertaining your application to info@cancercopayrelief.

In completing this 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.

Please deliver a copy of the Physician Verification form to your oncologist and have their office mail it directly to us.

When you complete this application please also mail the additional items listed bellow to our mailing address:
Cancer Copay Relief
2275 Smith Avenue SW
Marietta, GA 30064

Extra items not included in the online application that we will need to process your application:

• 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.

(If yes, do you have medical/prescription coverage through the VA?)

Patient Advocate Helping You (if applicable)

Step 2. Insurance Information
Primary Insurance

Note: You are asked to submit a photocopy of the front and back sides of all insurance cards. Please make sure that all identification and phone numbers are legible, and that all information is correct, and current.

Primary Insurance Financial Information

The amount you pay before insurance begins coverage.

The total amount before insurance pays at 100%.

The maximum amount insurance will pay in a calendar year, after which you are responsible for 100% of debt incurred.

Pre-determined amount you pay for each prescription.

Pre-determined amount you pay for each office visit.

Secondary Insurance

Note: You are asked to submit a photocopy of the front and back sides of all insurance cards. Please make sure that all identification and phone numbers are legible, and that all information is correct, and current.

Secondary insurance financial information

The amount you pay before insurance begins coverage.

The total amount before insurance pays at 100%

The maximum amount insurance will pay in a calendar year, after which you are responsible for 100% of debt incurred.

Pre-determined amount you pay for each prescription.

Pre-determined amount you pay for each office visit.

Medicare Part D (if applicable): Standard Prescription Drug Plan

.

If you are unsure of this information ask your pharmacist for a printout of your Out-of-Pocket expenses paid to date.

Step 3. Please provide your current yearly income

Note: You are asked to submit financial documentation. Please make sure that the information is current, legible, and complete.

Please provide the current yearly income of your spouse

Note: You are asked to submit financial documentation. Please make sure that the information is current, legible, and complete.

Step 4. Prescribing Physician Information

Pharmacy

Infusion Provider (if applicable)

Your Medication and Copayment Costs
Please list all the copayments you make in a month, and their costs. Attach additional sheets of paper to the back of the application if needed.

Is there another cost weighing heavily on you at this time? Please explain.

Patient Consent

I certify that:
• I am legally able to sign this application.
• The information provided is accurate and complete.
• I am not receiving assistance from another organization to pay for my copayments.
• I will contact Cancer Copay Relief should my insurance status, doctor, pharmacy, and/or infusion
therapy provider information change.

I hereby allow Cancer Copay Relief to:
• Verify the information in this and subsequent applications to make sure it is complete and true.
• Share my information with those helping Cancer Copay Relief.
• Contact me by mail, phone, or email about Cancer Copay Relief, and/or other programs that might
serve me.
• Share my information with the pharmacy that may supply my medicine, and also the physician that
prescribed my medicine.
• Share my information with my doctor’s office.

I understand that Cancer Copay Relief will only use my information to:
• Assess whether or not I qualify for the program.
• Assist the work-flow of the foundation.
• Communicate with insurance plans, and/or other medical offices.

I further understand that:
• Cancer Copay Relief is not in any way liable for my cancer treatment; it’s successes, failures, accuracies,
or any harm done to me by the treatment.
• Cancer Copay Relief may ask me for further information at any time.
• Assistance may change or stop at any time, for any reason with or without notice.
• If I am found to have falsified information, leading toward financial assistance, I may be found liable for
the cash amount granted, and will have to refund it to Cancer Copay Relief.
• I can withdraw from the foundation at anytime by sending my request in writing to: accounts@cancercopayrelief.org

If this form was completed by an advocate, I also grant permission for Cancer Copay Relief to contact them to further help my application.