Relief Program Application

Needs Beyond Medicine’s Relief Program creates financial assistance grants for individuals in cancer treatment. These grants can be used to supplement living expenses not classified as a medical expense. Examples of such living expenses are transportation costs, groceries, utilities, rent and more. These grants help to provide much needed relief for adults facing the greatest fight and period of hardship in their lives.
‍In 2024, the maximum amount a patient is eligible for is $575. Must be a current Utah resident.

Items Needed for Application Review in 2024:
- Treatment Plan & Diagnosis template (please download and attach)
- Any items missing, your application will not be reviewed ‍(No phone calls or emails, all applicants will be contacted)

Please download the diagnosis and treatment planTREATMENT PLAN & DIAGNOSIS TEMPLATE

Upload Verification of Diagnosis

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Patients InformationFull NameMailing AddressCityStateZip CodeDate of BirthGenderPhone NumberEmailMarital StatusHousehold Size (including yourself, spouse, and all dependents)RaceEmployment StatusIf applicable, name of your employerYearly household income (Please use current amount, if unemployed or on leave)Do you have medical insurance?If yes, what is the name of your medical insurance provider?Military StatusType of cancer diagnosisStage of cancerDate diagnosed with cancer (Most CURRENT diagnosis)Is this a relapse of cancer?If yes, Original Diagnosis Type & DateName of your doctorAre you currently in active treatment? (prescription pills are not considered treatment)What type of treatment are you receiving (Please mark appropriate treatments you are receiving, use CTRL for multiple)Date current treatment beganLength of treatment (estimate an end date if possible)Medical facility where you receive treatment?Have you previously applied for Needs Beyond Medicine financial assistance?If yes, what month/year you applied?Purpose of financial assistance requesting from Needs Beyond Medicine (Select all that apply, use CTRL for picking multiple)Please elaborate on your requested assistance. How did you hear about Needs Beyond Medicine?Did a person or medical office refer you to us? Please nameTheir phone number

I hereby certify that all the information provided on this form is true and correct. I understand that providing false information leads to denial of my application.
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Relief Program Appilcation