Justin Jason Test – Family Reach Application

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Financial Resource Center Application

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)?

Household Income: Number of People in Household:

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.

Patient Criteria*

Check here to confirm that the patient meets the criteria given above before proceeding*

Disclosure

Disclosure*

Check here to confirm you have read our disclosure before proceeding*

To determine if you are eligible for Family Reach’s services, Family Reach will obtain information about the patient’s health condition and treatment plan, as well as your family’s finances, living situation, and personal expenses.

Family Reach is not a healthcare provider, insurer, clearinghouse, or a business associate of any healthcare organization. As such, none of the information that you provide — or that others provide on your behalf — to Family Reach is subject to the Health Insurance Portability and Accountability Act (HIPAA).

It is the aim and intent of Family Reach to utilize the information that you provide — or that others provide on your behalf — to Family Reach to determine if you are eligible for Family Reach’s services. To do that, Family Reach may need to share information about you or your family with third parties or obtain additional information about you or your family from third parties.

You or others acting on your behalf may provide Family Reach with information in electronic form. Information that is provided to Family Reach in electronic form via Family Reach’s application is maintained on Family Reach’s behalf by Salesforce.com. Information explaining how Salesforce.com maintains and safeguards that information, can be found HERE

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*

MM slash DD slash YYYY

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 (optional)

Primary Contact Information

Primary contact name*

First name

Last name(s)

Relationship to patient*

Primary contact phone (optional)

Primary contact email

Enter email

Confirm email

Preferred Contact Method

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

Preferred contact method*

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

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*

MM slash DD slash YYYY

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*

MM slash DD slash YYYY

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*

Household Information

Number of people in household*

Please enter a number from 1 to 30.

Please enter the number of people in the patient’s household.

This number includes the patient and anyone who shares financial responsibility with or for the patient.

Are there children under the age of 18 in the household?*

Yes

Are there children with disabilities in the household?*

Yes

Household Veteran Status*

Is the patient or anyone in the patient’s household a veteran of the United States Armed Forces?

Household income*

Please enter a number from 0 to 999999.

How much is the household expected to earn this year?

Please describe the patient or family situation.*

Please tell us more about the patient or family situation, such as names, ages, relation of household members, and how cancer has impacted them financially.

Financial Needs

Is the patient or family currently (or at risk of) experiencing houselessness?*

Yes

Is the patient or family behind on rent or mortgage?*

Yes

Is the patient or family behind on utilities (electric or gas)?*

Yes

By how many months*

How many months is the patient or family behind on rent/mortgage?

By how many months*

How many months is the patient or family behind on utilities?

Insecurity

Please select the types of insecurity that the patient or family is experiencing.

Food/Water*

Yes

Phone/Internet*

Yes

Transportation*

Yes

For each financial need or insecurity identified above, please provide additional details.*

Service Info

Based on your responses, the applicant likely qualifies for assistance.

Please indicate which service(s) you would like to request for this patient below.

Are you requesting financial assistance for this patient?*

Yes

Are you requesting food or transportation services for this patient?*

Yes

Are you requesting resource navigation for this patient?*

Yes

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

Preferred contact method*

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

Yes

Service Requests

Use the "Add Service Request" button to add one or more services that the household requires.

After adding the requests to the application, be sure to complete this application or hit "Save and Exit" before working on a different application.

Vendor information

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

There are no Service Requests.

Maximum number of service requests reached.

Total amount requested:

Total Amount Requested

Summary of Your Patient Application

Please review your application details below, ensuring all information is accurate and complete then click the 'Submit' button to finalize the application.

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