Family Reach Application

Resource Application

1Eligibility

2Patient Info

3Medical Info

4Household Info

5Resource Info

6Application Summary

Fund Selection

Review the guidelines and eligibility criteria for the currently available funds that are listed in the portal and select ONE that matches the patient’s situation.

Family Reach DOES NOT accept applications for multiple funds for the same patient, and we will only review applications that match currently available funds.

Which fund are you applying for?*

Eligibility and Disclosure

This application will ask about the patient’s cancer experience and household expenses. Please answer as accurately and completely as possible.

Before getting started, let’s confirm eligibility. To be considered for financial assistance patients must:

Have a cancer diagnosis
Be receiving active treatment in the US or a US territory
Meet income guidelines of 300% of the Federal Poverty Level (FPL) or below

Have a cancer diagnosis
Be receiving active treatment in the US or a US territory
Meet income guidelines of 300% of the Federal Poverty Level (FPL) or below
The patient identifies as Black and/or Hispanic/Latino

For the purposes of providing financial assistance through Family Reach, “active treatment” includes any treatment that is intended to cure, slow the progression, or prevent the recurrence of an individual’s cancer, such as: surgery, radiation, chemotherapy, immunotherapy, targeted therapy, biosimilars, stem cell and bone marrow transplant and CAR T-cell therapy. Active treatment DOES NOT include reconstruction surgeries, long-term hormonal therapies, palliative care, or hospice care, as these are not intended to cure, slow the progression, or prevent the recurrence of cancer.

Family Reach acknowledges that the types of treatment that an individual may engage in to treat their cancer vary by personal/cultural beliefs and practices. We are committed to considering all forms of treatment that are intended to actively treat a patient’s cancer.

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Patient Information

Name*

First name

Last name(s)

Marital status*

Date of birth*

Based on this patient’s age we suggest selecting another family member as primary contact

Is the patient the best person in the household to contact about this application?*

Yes the patient is the primary contact

Another family member or friend is the primary contact

Enter patient’s email

Confirm patient’s email

Patient's phone number

Primary Contact Information

Primary contact name*

First name

Last name(s)

Relationship to patient*

Primary contact phone

Primary contact email

Enter email

Confirm email

Patient Address

Address*

Street address

Address line 2

City

State / Province / Region

ZIP / Postal code

Country

Patient Demographics

Prefer not describe ethnicity

Prefer not to describe the race or ethnicity of the patient

Race*

Select all that apply

Does the patient identify as Hispanic or Latino?*

Gender identity*

Preferred language*

Insurance

Insurance type*

Select all that apply

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Social Worker

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Social worker name

First name

Last name(s)

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Title

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Phone

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Social Worker Email

Confirm email

Hospital or Treatment Center

Hospital or Treatment Center*

Unable to find hospital or treatment center

Name of Hospital or Treatment Center*

Cancer Diagnosis

Please select cancer diagnosis*

What stage?*

Other diagnosis

Date of initial diagnosis*

Please provide your best estimate. If you do not know the exact day, enter the first day of the month (ex: 03/01/2023).

Recurrence

Is this a recurrence?*

Date of most recent recurrence*

Please give us your best estimate, If you are not sure of the exact day enter the first of the month. (Ex. 03/01/2003).

Current Treatment

Patient's current treatment status*

Is the patient on a clinical trial?*

What clinical trial stage?*

Clinical Trial Details

Enter either the NCI ID or NCT ID for the clinical trial. If you don’t know the ID number, you may use the State and Clinical Trial Site selectors and the keyword field to search the National Cancer Institute database.

Clinical Trial Site

Keywords

NCI ID / NCT ID*

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Resource Application

Fund Selection

Eligibility and Disclosure

Patient Information

Primary Contact Information

Patient Address

Patient Demographics

Insurance

Social Worker

Hospital or Treatment Center

Cancer Diagnosis

Recurrence

Current Treatment

Clinical Trial Details

Household Information

Financial Needs

Insecurity

Resources Available