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Patient Assistance Forms

Financial Assistance Application

We have reached our limit for enrollments in our Lazarex CARE travel reimbursement program for 2023 and are not accepting new applications for the Lazarex CARE program for the remainder of this year. We will resume accepting new applications on April 1, 2024.

  • Patients who are currently enrolled in the Lazarex CARE program will continue to have expenses reimbursed. 
  • Given existing grant funds, Stand Up to Cancer applications will continue to be accepted.
  • We will resume accepting new applications on April 1, 2024.

The Lazarex Clinical Trial Navigation Program remains in operation and is accepting new questionnaires.

Patient Navigation Questionnaire

This form is for assistance with Clinical Trial Navigation.  Use this form if you would like our help identifying cancer clinical trial options for yourself or on behalf of someone else. 

If you have questions please contact Lazarex Cancer Foundation directly for for help with clinical trial identification.

Complete the Patient Navigation Questionnaire

Trial Verification Form (TVF)

Use this form to verify cancer clinical trial status for APPROVED & ENROLLED Lazarex patients only. Have a Medical Representative (oncologist, nurse, doctor, social worker or clinical trial coordinator, etc.) complete the form.

It is the patient’s responsibility to submit the completed form to Lazarex Cancer Foundation by the requested due date. 

If you have questions please contact Lazarex Cancer Foundation directly for assistance.

Click HERE to access the online Trial Verification Form  

Patient Navigation Questionnaire
Trial Verification Form for approved and enrolled Patients of Lazarex Cancer Foundation