Request for Assistance

Assistance Request and Patient Background

*Note all information provided is strictly confidential and will only be used by a Luna Cares board member to determine the best means for patient assistance.
Contact The Luna Cares Fund however you feel most comfortable:
Download & remit ASSISTANCE APPLICATION form

Visit us on Facebook, or
Send us an email directly

or by completing the below Assistance Request Form

Request For Assistance

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Gender *

Date of Diagnosis *

Stage *

Primary Cancer *

New Diagnosis *

Recurrence *

Are you in active treatment *

Has the patient previously applied for Luna Cares Assistance? *

If yes, when? *

Does the patient have health insurance? *

Is the patient currently employed? *

Number of people in the household *

Has the patient's household income changed since the diagnosis? Please explain *

Is there anyone else information may be given to in the event the patient is unavailable? *

Name of alternate contact *

Treating Physician Name: *

First

Last

Treating Physician Phone Number: *

Physician Office or Hospital Address: *

I understand all information I submit is subject to verification by Luna Cares. I also understand if I fail to provide requested information, my application will not be processed.

Signature *

Date *

Submit