Patient Information Form - Angel Foundation

Please inform us why you are in need of Emergency Financial Assistance.*

Patient Information

Name*

First Middle Initial Last

Date of Birth*

Address*

Street Address Apartment Number City State ZIP Code

County*

Other County (please list)

Phone*

Will you need language translation if we call?*

Yes
No

If yes, which language do you speak?*

Is it okay to leave a message on your phone?*

Yes
No

Email*

Inform me regarding my application via:*

Email and mail
Mail only

Name of Employer*

Please note we will not contact your employer

Name of Medical Insurance Provider*

If you have no insurance, please type none.

Demographic Information

This 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?*

Yes
No

Racial Identity*

Two or More Races (specify)*

Other (specify)

Marital Status*

Other (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 State ZIP Code

Phone

Email

Relationship to patient

Medical Information

Diagnosis*

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*

Oncologist/Radiologist/Surgeon/Urologist Name*

Prefix First Last

Clinic or Hospital Name*

Clinic or Hospital Location*

City

Clinic or Hospital Phone*

Household Information

Please list all the people living in your household*

If no other family members in the household, enter None

Full Name	Date of Birth (please use MM/DD/YYYY format)	Relationship

Financial Information

Total Monthly Household Income (After Taxes)*

Estimated Household Assets (Do Not Include Retirement Accounts):*

If none, enter 0.

Checking	Savings/CD	Other

Total Estimated Household Assets*

(Money the patient has access to without penalty)

Patient Release Form

Consent*

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 agree

Name*

I understand that this serves as my digital signature

Date

Additional Information

Please take some time to answer the questions below

Would you like to be on Angel Foundation's mailing list?

Yes
No

Would 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.

Yes
No

How did you hear about Angel Foundation?

Name of referring person

Other (please explain)

Additional Information

Please provide additional comments regarding your situation that might be helpful when reviewing your application.