Patient Information Form Patient Information Form Application for Emergency Financial Assistance. Please note, this application will ask for financial information such as total monthly household income (after taxes) and current balances for checking, savings and investment accounts. It may be helpful to have these figures handy when filling out the application. Please inform us why you are in need of Emergency Financial Assistance.*Patient InformationName* First Middle Initial Last Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Apartment Number City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*AnokaCarverDakotaHennepinRamseyScottWashingtonOtherOther County (please list)Phone*Will you need language translation if we call?*YesNoIf yes, which language do you speak?*Is it okay to leave a message on your phone?*YesNoEmail* Inform me regarding my application via:*Email and mailMail onlyName of Employer*Please note we will not contact your employerName of Medical Insurance Provider*If you have no insurance, please type none.Demographic InformationThis information is used for statistical reporting when Angel Foundation applies for grants to support our ability to provide free programs and services. No individual information is released, and information provided will not impact whether or not you receive assistance.Gender* Female Male Prefer not to answer Other Other (specify)Veteran?*YesNoRacial Identity*African American/BlackAmerican IndianAsianCaucasian/WhiteHispanic/LatinoHmongMiddle EasternPacific IslanderTwo or More RacesOtherPrefer Not to AnswerTwo or More Races (specify)*Other (specify)Marital Status*SingleMarriedDivorcedSeparatedPartnered/In a RelationshipWidowedOtherPrefer Not to AnswerOther (specify)Responsible Party (if different from above)This section is only necessary if you are completing the application for someone else. If you are the person applying for assistance, please skip to the household section.Name First Last Address Street Address Apartment Number City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Relationship to patientMedical InformationDiagnosis*Patient's Current Treatment*Check all that apply Chemotherapy Radiation Bone Marrow Transplant Surgery Palliative Care Hospice Not Currently in Treatment Date of Last Treatment Received* Date Format: MM slash DD slash YYYY Oncologist/Radiologist/Surgeon/Urologist Name* Dr.Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Clinic or Hospital Name*Clinic or Hospital Location* City Clinic or Hospital Phone*Household InformationPlease list all the people living in your household*If no other family members in the household, enter NoneFull NameDate of Birth (please use MM/DD/YYYY format)Relationship Financial InformationTotal Monthly Household Income (After Taxes)*Estimated Household Assets (Do Not Include Retirement Accounts):*If none, enter 0.CheckingSavings/CDOther Total Estimated Household Assets*(Money the patient has access to without penalty)Patient Release FormConsent*I declare that the information on this application is true and correct to the best of my knowledge. I understand that all applications will be reviewed on a case-by-case basis and final determination will be made by Angel Foundation. I hereby give my permission that this application and all information provided can be sent to Angel Foundation and discussed with my health care professional. All information reviewed is confidential. I agreeName*I understand that this serves as my digital signatureDate Date Format: MM slash DD slash YYYY Additional InformationPlease take some time to answer the questions belowWould you like to be on Angel Foundation's mailing list?YesNoWould you be willing to share your story with our community?If you choose yes, someone from Angel Foundation will contact you for more information. This is not required to receive assistance.YesNoHow did you hear about Angel Foundation?Social WorkerNurseOncologistPatient Financial CounselorPatient NavigatorFriendInternetBrochureOtherName of referring personOther (please explain)Additional InformationPlease provide additional comments regarding your situation that might be helpful when reviewing your application.