Sarcoma-Oma | Foundation Patient Travel Funding Application

APPLICATION FOR MEDICAL TRAVEL FUNDING

Please allow one week for our staff’s initial response to your application.
We are well aware that your needs are extremely time sensitive.

PATIENT

First Name: Middle Initial:

Last Name:

Email:

Address:

City: State: Zip code:

Phone:

Social Security Number:

PERSON COMPLETING THE APPLICATION

Relationship to patient:

First Name: Middle Initial:

Last Name:

Email:

Address:

City: State: Zip code:

Phone:

REFERRING PHYSICIAN

Name:

Address:

City: State: Zip code:

Phone:

HOW DID YOU FIND OUT ABOUT OUR ORGANIZATION?

BRIEF DESCRIPTION OF DISEASE

BRIEF DESCRIPTION OF DESIRED TREATMENT

DO YOU ANTICIPATE ADDITIONAL TRIPS?

IF SO, HOW MANY?

LOCATION OF FACILITY FOR CONSULATION AND/OR TREATMENT DESIRED
ALONG WITH CONTACT INFORMATION

HOW LONG IS YOUR ANTICIPATED STAY?

WHAT IS UNIQUE ABOUT THE CARE YOU WILL BE RECEIVING AT THE FACILITY
TO WHICH YOU DESIRE TO TRAVEL?

WHAT WAS YOUR CAREER/TYPE OF EMPLOYMENT BEFORE YOU WERE AFFLICTED
WITH YOUR DISEASE?

WHAT DO YOU MISS MOST FROM YOUR LIFE BEFORE YOU BEGAN BATTLING
YOUR DISEASE?

ANY ADDITIONAL COMMENTS YOU'D LIKE TO SHARE?

PATIENT'S EMPLOYER

Patient Job Title:

Name:

Address:

City: State: Zip code:

Annual Income:

SPOUSE'S EMPLOYER

Name:

Address:

City: State: Zip code:

Annual Income:

By checking this box, I hereby authorize the Sarcoma-Oma Foundation to contact any employer referenced on this application to verify employment and stated income.

My signature below verifies that the information that I have provided is true and correct to the best of my knowledge and belief.

Please type your full name as your signature:

Date: