Request Financial Assistance

The South Jersey Cancer Fund (SJCF)meets bi-weekly to review all requests for financial support and will consider payment of expenses related to treatment and care related to your cancer diagnosis. SJCF is NOT an emergency fund. Please continue to pay all bills, even in you pay a minimal amount. Contact the vendor/provider for payment arrangements if necessary. Please return completed form, with attached bill(s) to South Jersey Cancer Fund, P.O. Box 1084, Brigantine, NJ 08203

Patient’s Name:

DOB:

Patient’s Cancer Diagnosis:

Date of Diagnosis:

Patient Address:
Street:

Town:

State:

Zip:

Patient Phone Number:

Patient Email:

Caregiver Name:

Care Giver Phone Number:

Physician Name:

Physician Phone Number:

Social Worker Name:

Social Worker Phone Number:

What help are you requesting?

Health Insurance Coverage Company:

Medicare coverage:

A B Supplemental

Own or Rent Residence:

Monthly Mortgage/Rent:

Employment Status:

Did you file for NJ programs?

LIHEAP/Universal Service Fund:

House Counseling Agency:

Pharmacy Assistance Programs:

Transportation Services:

The South Jersey Cancer Fund meet bi-weekly to review all requests for financial support. The South Jersey Cancer Find is NOT an emergency fund. Please continue to pay all bills, even if you pay a minimal amount. Contact the vendor/provider for payment arrangements if necessary.

Request Financial Assistance

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