Borland Groover Foundation - Financial Assistance Program

Financial Assistance Program

Please complete the form below to apply for the Financial Assistance Program
Important: Any missing information may delay the application process. Be sure to fill out the application entirely and attach all supporting documents.

Please allow 14-30 business days for the application process to be completed, thank you!
Full Name*

First NameMiddle NameLast Name
Sex*

MaleFemaleOther
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address*
Type of Cancer*

Colon CancerRectal CancerAnal Cancer
Date of Diagnosis *

MonthDayYear
Date
In order to process this application, we need a few details.

Please tell us your household size and monthly income:
The number of family members (including you) who live in your home. May include a spouse or qualified domestic partner, children, a non-parent caretaker relative, etc.
Household Size*
Number including yourself
Total gross annual income*
Annual income for all family
Household Income Check ALL income types that apply:*

Employment income wagesUnemployment Benefits/Disability IncomeBusiness income/Rental PropertyAlimony/Child SupportPension or Retirement AnnuitiesSocial Security/Supplemental Security Income/Veterans Benefits
Please attach most recent income tax return*

Browse Files

Cancelof
Who is submitting this form on behalf of the person applying for financial aid?*

PatientPatient's Family MemberMedical Office
Name of person submitting form on behalf of patient

First NameLast Name
Email of person submitting form on behalf of patient
example@example.com
Phone Number of person submitting form on behalf of patient

Area CodePhone Number
Healthcare costs: Total out-of-pocket expenses that accrue since the diagnosis of your cancer. Funds are available for one (1) year after being accepted by the foundation for medical services relating to gastroenterology care from a health care provider based in North Florida. May include copays, deposits, coinsurance, or deductible payments for eligible medical services. For reimbursement, please submit bills with the explanitation of benefits from insurnace company.

EMAIL
Foundation@BorlandGroover.com

FAX
904.483.5874
If you are uninsured, the Borland Groover Foundation may be able to help.
I would like to be contacted by:

PhoneEmail
I hereby declare under penalty or perjury that all information set forth above in this application is true and accurate in all respects. *

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