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Financial Assistance
Request Form

We are a nonprofit organization providing limited financial & educational assistance to children and adults undergoing cancer treatment in MANISTEE and MASON COUNTY.  You must reside in one of the counties we serve in order to be eligible for financial assistance.  If you are requesting financial assistance please fill out this form and submit it online. We process request forms monthly and will contact 
you when your request is reviewed.  

 

Please email us at info@soc-­‐fund.org, if you have questions. 

Financial Assistance Request Form

PATIENT INFORMATION

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MEDICAL HISTORY

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FINANCIAL INFORMATION

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I verify that the information provided in the application is complete and accurate.  I further understand that I may be asked to provide proof of the reported financial information on the application if asked by the SOC FUND. I verify that I have provided the information for payment/pending payment for financial assistance from sources other than the SOC FUND.

 

I recognize that the SOC Fund is providing full or partial financial assistance for the service described in this application as deemed medically necessary by my healthcare provider (s).  SOC Fund is in no way liable for the success/failure of this service or for any harm to my health that it may cause.  I authorize the SOC Fund and its agents to obtain and discuss information related to the application process with my prescribing physician, pharmacy, employer, insurance company, or other organizations working on my behalf of obtaining services.  The SOC Fund and/or its agents or authorized designee agrees not to disclose any individually identifiable information to any third party, except as provided herein or except as required by law.  The SOC Fund can, however, use the data to develop aggregate reports as directed by its Board of Directors.

 

I understand that the SOC Fund reserves the right at any time and without notice to modify or discontinue any or all of the programs with respect to any applicant or in their entirety, to modify the related eligibility criteria, or to terminate assistance at any time. 

Thank you! Your request has been sent for review.

****** FOR SOC-FUND USE ONLY******

Additional Questions:

Answers/Comments:

Amount Approved  $

Date Approved

Patient Notified    YES    NO                       Comment:

Date

Signature

Date Funds Dispersed

Initials

Initials

Online form

Updated 11/2022