Relief Program Application 2022

Please fill out the form below, make sure to answer all questions.
Applicants must be residents of Utah.
Patient must be in active cancer treatment.
Total amount not to exceed $500 of requested assistance.

Relief Program Application

First Name *

Last Name *

Address *

City *

State

Zip *

Date of Birth *

Gender *

Phone Number *

Email *

Marital Status: *

Number of People in household, Adults: *

Race/Ethnicity *

Employment Status *

If applicable, name of your employer: *

Annual Household Family Income: *

Do you have medical insurance? *

If yes, what is the name of your insurance company? *

Military Status: Are you active duty or retired military? *

If so are you eligible for VA Benefits? *

Previously applied for assistance from NBM? *

If yes, date received *

What are you requesting financial assistance for?

WE WILL NOT COVER MEDICAL RELATED EXPENSES. YOUR APPLICATION MAY BE REVOKED IF YOU ASK FOR FINANCIAL ASSISTANCE FOR MEDICATION OR OTHER MEDICAL COSTS ASSOCIATED WITH TREATMENT.

Rent/Mortgage *

Transportation *

Groceries *

Utilities *

Recovery Items *

Other (Specify) *

Other resources you have tried (check all that apply) *

Type of Cancer *

Stage of Cancer *

Date of Diagnosis (Most CURRENT diagnosis) *

Relapse of Cancer *

If Yes, Original Type & Date *

Name of your Doctor *

Are you currently in active treatment? (chemotherapy/radiation treatments/etc.) Surgeries/prescription pills are not considered treatments *

If No, when will you start treatment? *

What type of treatment are you receiving? (BE SPECIFIC) *

Date treatment began *

Length of treatment (estimate and end date if possible) *

Medical facility where you receive treatment *

How did you hear about Needs Beyond Medicine? *

Did a person or medical office refer you to us? Please name: *

Their Phone number: *

Their Address *

City *

State *

Zip *

Applicant Signature *

Date *

Relief Program Application 2022

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