Patient Aid Fund

Patient Aid Fund is sponsored by Leukemia & Lymphoma Society. This fund offers financial assistance for blood cancer patients of all ages.

* Lymphoma and the Immune System * Awaiting or Recently Diagnosis * Remission or Survivorship * Caring for Someone with Lymphoma * Lymphoma Resource Center * Talk to Our Support Team * Treatment Navigation Services * Become a Corporate Partner * Join the Lymphoma Support Network * Research Initiatives & Scientific Programs * Research Grant Programs * For Healthcare Professionals * Lymphoma Rounds CME Program * Resources For Your Patients * Lymphoma and the Immune System * Awaiting or Recently Diagnosis * Remission or Survivorship * Caring for Someone with Lymphoma * Lymphoma Resource Center * Talk to Our Support Team * Treatment Navigation Services * Become a Corporate Partner * Join the Lymphoma Support Network * Research Initiatives & Scientific Programs * Research Grant Programs * For Healthcare Professionals * Lymphoma Rounds CME Program * Resources For Your Patients * Lymphoma and the Immune System * Awaiting or Recent Diagnosis * Remission or Survivorship * Caring for Someone with Lymphoma * Lymphoma Resource Center * Talk to Our Support Team * Treatment Navigation Services * Become a Corporate Partner * Join the Lymphoma Support Network * Research Initiatives & Scientific Programs * Research Grant Programs * For Healthcare Professionals * Lymphoma Rounds CME Program * Resources For Your Patients # 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: * 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 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) Patient's Date of Birth(Required) Name of Guardian (if applicable) 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. Patient's Mailing Address(Required) Street Address City State ZIP Code Is the patient a US Resident?

(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. Net Household Income (Monthly) Monthly Expenses(Required) Do you have health insurance?

(Required) Health Insurance Carrier(Required) Health Insurance Type(Required) Certification and Disclaimer(Required) - [x] I certify that the foregoing information is true and correct.

If my application for a Lymphoma Research Foundation’s Patient Aid Grant program is accepted, I understand and agree that there are risks, both foreseeable and unpredictable, associated with transportation, housekeeping services, equipment, or other goods, programs, or services funded by this grant. I am aware of these risks and agree that my use of these goods or services is at my own risk.

I hereby agree that the Lymphoma Research Foundation nor its officers, directors, employees, agents, members, or volunteers, shall not assume or have any responsibility or liability, including without limitation of any kind in connection with this grant liability for expenses or medical treatment or compensation for any injury I may suffer during or resulting from my use of the grant.

I do hereby, for myself, my heirs, executors, and administrators, waive, release, and forever discharge any and all rights and claims for damages that I may have or that may hereafter accrue to me arising out of or in any way connected with my use of this or any future grant funding.

I give Foundation or their designee permission to contact my physician (nurse/social worker when applicable) based on the information I have provided within this grant application. I will comply with any rules or restrictions related to the terms of this grant if I should be a recipient.

### To continue, please click on Continue to Next Section ### To continue, please click on Submit to Care Team for Physician Referral Continue to Next Section Submit to Care Team for Physician Referral Click here if you are a Social Worker or Nurse assisting in the completion of this application.

- [x] 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) Institution Address(Required) Street Address City State ZIP Code Email Address (Social Worker/Nurse)(Required) ### Physician Referral Section Patient's Diagnosis(Required) Date of Initial Diagnosis(Required) Confirm Patient's Name(Required) 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) Institution/Affiliation(Required) - [x] By checking this box, I certify that I am a member of the patient’s medical care team (ex. physician, social worker, nurse, etc.) and that the above information is true and correct.

Return to Patient Information Continue Submit to Care Team for Physician Referral ### Application Submission Please note: the Foundation’s Financial Assistance Program grant eligibility is those who have been diagnosed with Lymphoma or Chronic Lymphocytic Leukemia (CLL) and are currently in active treatment or have completed treatment within the past year.

Previous Submit Application Submit to Care Team for Physician Referral The Lymphoma Research Foundation’s mission is to realize the promise of science to eradicate lymphoma and serve the community touched by this disease. 800-500-9976| [](mailto:HELPLINE@LYMPHOMA. ORG)connect@lymphoma.

org Wall Street Plaza, 88 Pine Street, Suite 2400, New York, NY 10005 Step 1 of 3, Patient Information