GRACE Application

Application for Cancer Patient Funds

Application Form
Diagnosis Verification Form
Authorization for Disclosure of Health Information

Directions for Completing the Packet

  1. Complete the Application Form -- (All areas must be completed except those marked Grace Rep. Please give as much information as possible.)
     
  2. Complete the Authorization for Disclosure of Health Information -- This form must be filled out by the applicant before seeing your doctor. The doctor must see this form to verify your diagnosis.
     
  3. Complete the Diagnosis Verification Form -- This form must be completed by your doctor.
     
  4. All three forms listed above must be returned to the GRACE, Inc. board to have your request acted upon.

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