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Let's Get Busy for Izzy!

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Empowering Cancer Fighters: Financial Support Application

Izzy’s Legacy Inc is here to offer financial support to individuals and families dealing with a cancer diagnosis. To better serve you, we kindly request that you provide us with some necessary information regarding your diagnosis and financial situation. Please understand that your privacy is our top priority. We maintain strict confidentiality standards, and your health information will be used exclusively for the purpose of assessing your eligibility for support. Rest assured that your data will be securely stored, and access will be restricted to authorized personnel only. Your trust is valued, and we are dedicated to safeguarding your information.

The allocation of grants prioritizes patients who fulfill eligibility requirements and exhibit the most substantial financial need. Each patient is eligible for a maximum grant of $500.
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Name
Are you applying for yourself?
Emergency Contact Name
Do you have health insurance coverage?
Are you currently employed?
How many people are in your household, including yourself?
Are there any dependents or children in your household?
Do you have any outstanding medical bills related to your cancer diagnosis?
Do you have a support system in place, such as family or friends, to assist you during your treatment?
Are you experiencing any emotional or psychological challenges related to your diagnosis?
Do you have reliable transportation to and from medical appointments and treatments?
Are you experiencing any housing instability or concerns related to your diagnosis?
How were you referred to Izzy's Legacy Inc?
May we speak to your doctor?
Click or drag a file to this area to upload.

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