Relief Program Application

Program Overview
Needs Beyond Medicine’s Relief Program provides financial assistance to individuals undergoing active cancer treatment. Grants support essential non-medical living expenses including groceries, transportation, rent, and utilities, helping relieve financial burdens during a critical time.

‍‍Applicants must be current Utah residents.Eligibility Requirements
‍To be considered, all applicants must:
- Be undergoing active cancer treatment (verified separately).
- Submit a complete application.
- Provide a signed letter from an oncology nurse, doctor, or social worker verifying cancer diagnosis, current treatment plan, and financial need.

‍Applications with missing components will not be reviewed.

Applicant Acknowledgment
‍By submitting this application, I confirm the following: - All information and documentation provided are complete and accurate to the best of my knowledge. - Funds received from Needs Beyond Medicine will be used solely for essential living expenses outlined in the application.
- I will reside at the address listed on this application for at least 60 days to receive funds via the United States Postal Service.
‍- I understand that the status of my application will be communicated via phone or email (applicants do not need to contact the organization, this may result in disqualification of application).
‍- All information submitted will be treated as confidential and used solely for application evaluation.
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Eligibility Requirements:
To be eligible for a Relief Program grant, applicants must:
-Be currently undergoing active cancer treatment.
-Provide documentation from a medical professional confirming their diagnosis and treatment plan.
-Demonstrate financial need through a completed application process

Items Needed for Application Review in 2026:
- Treatment Plan on correct letterhead of facility receiving treatment.
- Any items missing, your application will not be reviewed
- Selected applicants will be contacted via phone call or email

Upload Diagnosis Verification of treatments
Required Verification (TO BE SUBMITTED WITH COMPLETED APPLICATION)
Please include a signed letter on official letterhead from your doctor, nurse, or hospital social worker confirming:
-Your current cancer diagnosis and stage
- Your active treatment plan
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Patients InformationFull NameMailing AddressCityStateZip CodeDate of BirthGenderPhone NumberEmailMarital StatusHousehold Size (including yourself, spouse, and all dependents)RaceAnnual Household Income Earned in the Last 12 Months?Employment StatusIf applicable, name of your employerDo you have medical insurance?If yes, what is the name of your medical insurance provider?Military StatusDo You have housing?If yes, is it:Requested Grant Amount (up to $575) Purpose of financial assistance requesting from Needs Beyond Medicine (Select all that apply, use CTRL for picking multiple)Have you previously applied for Needs Beyond Medicine financial assistance?If yes, what month/year you applied?Describe your current situation and why financial assistance is needed? (MUST BE ANSWERED)

Cancer Diagnosis & Treatment (To be filled out by applicant and verified by healthcare provider, must be on facility letterhead) UPLOAD AT BEGINNING OF APPLICATION Primary Cancer Diagnosis:Stage of Cancer: Date of Original Diagnosis:Is this a recurrence?Are you currently in active treatment?Treatments Received in Past 12 Months (Check all that apply) Facility Receiving Treatment At:Name & Title of Person Completing this Section (Include Full Name, Phone, Email & Relationship to Patient)

I confirm that the information provided in this application is accurate to the best of my knowledge. I understand that submission of this application does not guarantee approval of financial assistance.
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Relief Program Appilcation