Absorb Chaos | Give Back Calm | Provide Hope
This application form may be filled out by a cancer patient or by someone on behalf of the cancer
patient in need. Rocky Mountain Foundation of Hope (RMH) will equally consider everyone that submits
an application for financial assistance. We only pay medical bills associated with the care and treatment
of one’s cancer and cannot pay the patient directly. If you are interested, please complete the form
below and submit it for consideration. Someone from RMH will be in touch with you shortly.
Recipient Profile
Personal Information
First Name:
Last Name:
Birth Date (mm/dd/yyy):
Gender:
□ Female □ Male
Address Line 1:
Address Line 2:
City:
State:
Zip/Postal Code:
Country:
Email:
Phone:
Cell Phone:
Cancer Types:
Rocky Mountain Foundation of Hope | P.O. Box 630230 Lakewood CO 80163-0230 | 303.921.0475 | www.rockymountainhope.org
Absorb Chaos | Give Back Calm | Provide Hope
Treatment Information
Stage of Treatment:
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Newly diagnosed (has not begun treatment)
Currently in treatment (receiving chemo rounds/radiation/surgery/medications)
Finished treatment less than five years ago
Finished treatment five or more years ago
Living with cancer as a chronic illness (undergoing adjuvant therapy as a preventative or ongoing
procedure to contain cancer).
Doctor(s) and/or hospital(s) where care is being provided:
Biography /Background of Recipient:
Rocky Mountain Foundation of Hope | P.O. Box 630230 Lakewood CO 80163-0230 | 303.921.0475 | www.rockymountainhope.org
Absorb Chaos | Give Back Calm | Provide Hope
Narrative description of diagnosis and treatment (please provide as much information as possible. i.e.
recipient’s story and reason for funding):
Rocky Mountain Foundation of Hope | P.O. Box 630230 Lakewood CO 80163-0230 | 303.921.0475 | www.rockymountainhope.org
Absorb Chaos | Give Back Calm | Provide Hope
Payment/Financial Resources
How much aid is needed?
Total cost of treatment:
Does recipient carry medical insurance?
If so, what portion of the treatment is the insurance covering?
Does recipient work?
If so, what is the recipient’s salary?
Does recipient have savings or money in the bank to make payments?
How much money is needed to fund treatment that the recipient cannot cover?
*Please include copies of medical bills if requesting funds to cover a past treatment.
Rocky Mountain Foundation of Hope | P.O. Box 630230 Lakewood CO 80163-0230 | 303.921.0475 | www.rockymountainhope.org
Absorb Chaos | Give Back Calm | Provide Hope
Requestor’s Contact Information
I (the person submitting this form) am seeking services and/or information for:
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Myself – I have cancer
Myself – a family member or loved one has cancer
Patient/Client – I am a health professional
Best form of contact:
□ Email □ Phone □ Mail □ No Preference
If you are requesting assistance for someone other than yourself please also complete the following
information
First Name:
Last Name:
Address Line 1:
Address Line 2:
City:
State:
Zip/Postal Code:
Country:
Email:
Phone:
Cell Phone:
Rocky Mountain Foundation of Hope | P.O. Box 630230 Lakewood CO 80163-0230 | 303.921.0475 | www.rockymountainhope.org
Absorb Chaos | Give Back Calm | Provide Hope
Legal Disclaimer/Compliance
Signature
I, ____________________ declare the above statements are true under penalty of perjury.
Rocky Mountain Foundation of Hope | P.O. Box 630230 Lakewood CO 80163-0230 | 303.921.0475 | www.rockymountainhope.org