Family Reach Financial Treatment Program application

We understand gathering financial information from families can be difficult. We have created this guide to help gather information on the family’s income and financial needs to complete our Financial Treatment Program application. Emergency Relief is not guaranteed, and distribution of our Emergency Relief funds are based on numerous indicators including but not limited to severe loss of income, time missed from work, housing insecurity and out of pocket expenses. In addition to these financial questions, information about the patient’s name, demographics, and cancer type will also be asked.

Having a comprehensive understanding of how cancer treatment has financially impacted a family will help us match families to the most appropriate programs.

We encourage you to complete these questions with the families you are working with.

If the family is eligible for Emergency Relief, copies of bills will be collected at the time of application. Applications are assigned in the order they are received.

1. How much income has been lost since treatment began?: ❏ ❏ ❏ ❏ ❏

No household income Some Half Most All

2. Has the family used savings in the last 3 months? ❏ Yes ❏ No 3. What was the family’s last year’s annual income? _____________________ 4. Does the family receive long-term disability benefits, such as Social Security Disability Income (SSDI) or Supplemental Security Income (SSI)? ❏ Yes ❏ No 5. Has there been a loss of income due to COVID-19? ❏ Yes ❏ No 6. How many people contribute to the family’s income? _________________

*If two people contribute to household income, please answer the following question for each person:

7. Person 1: Cancer treatment can often limit a patient or caregiver’s ability to work or be employed. Over the past 3 months, how often was each person in the home NOT ABLE to work or be employed due to disability, illness, injury, or mental/emotional distress - either their own or a loved one's? ❏ ❏ ❏ ❏ ❏

The person was not able to work AT ALL The person was not able to work MOST of the time The person was not able to work ABOUT HALF of the time The person was not able to work SOME of the time The person’s ability to work was not impacted

7a. Person 2: Cancer treatment can often limit a patient or caregiver’s ability to work or be employed. Over the past 3 months, how often was each person in the home NOT ABLE to work or be employed due to disability, illness, injury, or mental/emotional distress - either their own or a loved one's? ❏ ❏ ❏ ❏ ❏

The person was not able to work AT ALL The person was not able to work MOST of the time The person was not able to work ABOUT HALF of the time The person was not able to work SOME of the time The person’s ability to work was not impacted

8. What financial needs are the family experiencing? Please check all that apply. ❏ ❏ ❏ ❏

Food insecurity Phone at risk of shut off Utilities at risk of shut off Behind on car payment or car insurance (how many months behind) _______ ❏ Unexpected emergencies such as car repairs, urgent home repairs, other family illness, divorce, etc... ❏ Unaffordable child care costs 9. Does the family pay rent or mortgage?

❏ Funeral costs ❏ Unaffordable insurance premiums and/or medical costs ❏ Travel over 50 miles for treatment ❏ Uncovered treatment related expenses like gas, public transportation costs, hospital food, etc

❏ Yes ❏ No 9a. Is the family behind on payments, and how many months are they behind? ❏ Yes ___________________ (months behind) ❏ No