Survey - LBBC Fund Verification of Applicant Diagnosis

LBBC Fund Verification of Applicant Diagnosis

Living Beyond Breast Cancer Fund
Verification of Applicant Diagnosis

Thank you very much for your assistance. Please feel free to contact us with any questions at grantinfo@lbbc.org or 855-807-6386, press #2.

Please respond to this question before continuing with this form. I am a:

Patient applying for the grant
Friend or family member
Healthcare provider

This form must be completed by a healthcare provider.

If you are not a healthcare provider, please do not complete this form. Please ask your provider to complete it for you.
If this form is not completed by your healthcare provider, it could create a significant delay in your application process.

The Living Beyond Breast Cancer Fund provides one-time financial assistance grants to people receiving active treatment for early stage breast cancer, or who are living with metastatic breast cancer, and experiencing financial concerns. In order to be considered for a grant, the applicant's healthcare provider must provide verification of breast cancer diagnosis.

Please complete this form on behalf of your patient. Demand for grants is very high. To expedite the review process for your patient, please submit this information as soon as possible.

By completing this form, I verify that my patient has been diagnosed with breast cancer.

Information about your patient applying for grant

Field Is Required Patient Legal Name (No nicknames):

Field Is Required Date of Birth:

Field Is Required Date of initial diagnosis:

Field Is Required Our grant review process requires a stage to be provided. Please indicate your patient's stage at initial diagnosis:

If Other stage, please describe.

Field Is Required Our grant review process requires a stage to be provided. Has the applicant been diagnosed with recurrent or metastatic breast cancer?

If Other stage recurrence, please describe.

If yes, please provide the recurrence/metastasis diagnosis date:

LBBC defines active treatment as surgery (lumpectomy or mastectomy only), chemotherapy, radiation, targeted therapies, and immunotherapy. We do not consider long-term hormonal therapies, such as tamoxifen or aromatase inhibitors, to be active treatment.

If Other procedure/treatment, please describe.

Field Is Required Please specify which procedures your patient has had within the past 30 days (check all that apply): Please make between 1 and 5 selections from the choices below.

Field Is Required Please specify which treatments your patient is having at this time (check all that apply): Please make between 1 and 6 selections from the choices below.

If Other treatment, please describe.

If Other future procedure/treatment, please describe.

Information for Healthcare Provider completing this form

Please provide your name and contact information:

Field Is Required First

Field Is Required Last

Field Is Required Email:

If you respond and have not already registered, you will receive periodic updates and communications from Living Beyond Breast Cancer.

Field Is Required Title:

Field Is Required Hospital/Practice Name:

Field Is Required City:

Field Is Required State/Territory:

Field Is Required Your direct phone number:

Thank you for completing this form. If you have questions, please contact us at (855) 807-6386, press #2 or grantinfo@lbbc.org.

Please note for your records the name of the patient(s) for whom you have completed a healthcare provider verification form.

Forms are valid for 90 days from the date received.

Additional information about the Living Beyond Breast Cancer Fund can be found at lbbc.org/fund.