Patient Aid Grant Application

If you’re feeling financial strain, we hope we can help. The Lymphoma Research Foundation offers Patient Aid Grants to help people undergoing treatment for lymphoma or CLL. Before starting this application, here’s what you’ll need to have on hand:

Income information
Your lymphoma diagnosis/subtype
An email address of a member of your care team (required for the physician referral portion)

Patient Aid Grant Application

Step 1 of 3 – Patient Information

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This field is for validation purposes and should be left unchanged.

Has the individual that this application is intended for been diagnosed with Lymphoma or Chronic Lymphocytic Leukemia (CLL), and is currently in active treatment or has completed treatment within the past year?(Required)

Name of Patient(Required)

First Last

Patient's Date of Birth(Required)

Name of Guardian (if applicable)

First Last

Applicant's Email Address(Required)

Enter Email Confirm Email

Please note that all information is confidential. The applicant and physician must complete all designated areas on the form prior to submission in order for it to be considered complete.

General Information

Patient's Mailing Address(Required)

Street Address City State ZIP Code

Phone Number(Required)

Is the patient a US Resident?(Required)

Occupation(Required)

Number of Dependents in Household (including self)(Required)

Financial Information

Statement of Purpose(Required)

Please describe what the grant support will be used for and explain how this grant would assist you and contribute to your quality of life.

Monthly Income(Required)

Net Household Income (Monthly)

Social Security Income

Public Assistance

Other Income/Grants

Total

Monthly Expenses(Required)

Rent/Morgage

Utilities

Telephone/ Cell Phone

Food

Medications

Car Premium/ Insurance

Gas to/from Treatment

Health Ins. Prem/CoPays

Total

Savings(Required)

Savings

Other

Stocks, Bonds, CDs

Investments/401K

Total

Do you have health insurance?(Required)

Health Insurance Carrier(Required)

Health Insurance Type(Required)

Today's Date(Required)

To continue, please click on Continue to Next Section

To continue, please click on Submit to Care Team for Physician Referral

Click here if you are a Social Worker or Nurse assisting in the completion of this application.

Click here if you are a Social Worker or Nurse assisting in the completion of this application:

Social Worker/Nurse Information

Social Worker/Nurse Name(Required)

First Last

Title(Required)

Institution(Required)

Institution Address(Required)

Street Address City State ZIP Code

Phone Number(Required)

Email Address (Social Worker/Nurse)(Required)

Physician Referral Section

Patient's Diagnosis(Required)

Cell Type(Required)

Grade(Required)

Subtype(Required)

Date of Initial Diagnosis(Required)

Confirm Patient's Name(Required)

First Last

Current Treatment(Required)

Please include any additional information below that you feel is important about this patient and their need for this grant:

This question is to be completed by a member of the patient’s care team only.

Physician's Information & Consent

Physician's Name(Required)

Prefix First Last Suffix

Institution/Affiliation(Required)

Phone Number(Required)

Today's Date(Required)

Patient Aid Grants