Application (FinalQA Sandbox)

Financial Resource Center Application (FinalQA Sandbox)

1Eligibility

2Patient Info

3Medical Info

4Household Info

5Service Info

6Application Summary

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GRAVITYFORM_UNIQUEID

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Notification Email address

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 that the patient meets Family Reach’s basic eligibility criteria.

Eligibility

Actively treated for cancer

Yes

Does this patient have a cancer diagnosis?

Live and treated in US

Yes

Is this patient receiving active treatment in the US or a US Territory?

For the purposes of providing services 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.

300% FPL

Yes

Does this household’s anticipated income for the current calendar year fall within 300% of the Federal Poverty Level (FPL)?

Based on your responses, the applicant likely qualifies to receive Family Reach services.

A Family Reach staff member will review to confirm eligibility and ensure the application meets any additional requirements for the service being requested.

Based on your responses, this household does not meet one or more of the basic eligibility requirements for receiving this service. We encourage you or the household to use our zip code searchzip code search to find other resources in your area.

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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.

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Which fund are you applying for?

Eligibility

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

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.

Disclosure

Referral

How did you learn about Family Reach?*

How did you learn about Family Reach?

Please specify*

Patient Information

Name*

First name Last name(s)

Marital status*

Date of birth*

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

Preferred Contact Method

Preferred contact method*

What is the household's preferred contact method for this service?

Is WhatsApp the ONLY way the household contact can be reached?*

Yes

At this time we do not have the capability to use WhatsApp, and are collecting information on how it is utilized. If the contact cannot receive calls to their phone without the use of the app, we will need to schedule time with them to call our navigator’s phone line.

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*

If you select a preferred language other than English, our Resource Navigator will reach out using an interpreter, and the interpreter will introduce themselves at the beginning of the call.

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

Email Confirm email

Hospital or Treatment Center

Unable to find hospital or treatment center

Name of Hospital or Treatment Center*

Healthcare Professional

Does the patient have someone at their treatment center or a community organization who is able to support them with navigating their experience with cancer (such as a social worker, patient advocate, etc.)?*

Yes

Unsure

Name (optional)

Title (optional)

Email (optional)

Phone (optional)

If contact information is provided, Family Reach may reach out to this person to coordinate services.

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*

Type of assistance	Name of person or vendor to pay	Amount requested	Actions

There are no Service Requests.

Financial Resource Center Application (FinalQA Sandbox)

Eligibility

Fund Selection

Eligibility

Disclosure

Referral

Patient Information

Primary Contact Information

Preferred Contact Method

Patient Address

Patient Demographics

Insurance

Social Worker

Hospital or Treatment Center

Healthcare Professional

Cancer Diagnosis

Recurrence

Current Treatment

Clinical Trial Details

Household Information

Financial Needs

Insecurity

Service Info

Service Requests

Summary of Your Patient Application