Applicant Information

Section 1: Statistical Data

Section 2: Medical Information

Section 3: Purpose of Request/Financial Information (monthly household gross income)

Section 4: Distribution - Supporting documents are required upon request.

All information I have provided is true and correct. I understand that any financial assistance provided by the Foundation is provided directly to my creditors, is limited, and is based on the immediate needs that negatively impact my health status. Application will expire 90 days from date of the application. Providing false information will result in denial of assistance. I authorize the Fredda S. Bryan Foundation to contact my health care provider(s) listed above, and I authorize my health care provider(s) to release information to the Foundation related to this application. If requested by my health care provider(s), I will complete an appropriate authorization to allow him/her to release information to the Foundation pertaining to this application. All information provided to the Foundation will remain confidential, except that the Foundation may disclose information to my creditors listed on the application and others as may be necessary to provide financial assistance. I understand that although the Fredda S. Bryan Foundation may consider billing cycles and due dates when providing financial assistance, I remain fully responsible for timely payments of my debts, and I will indemnify and hold harmless the Foundation for any expenses, losses, or liabilities arising from or related to my debts. To receive financial support, confirmation of a doctor’s supervision of care and testing recommendations must be submitted to the Foundation’s Cancer Assistance Program. I authorize my health care provider(s) to release information to the Foundation related to this application.