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Patient Assistance Forms

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.

Download the Patient Navigation Questionnaire

Financial Assistance Application

Use this form to request Financial Assistance for travel expenses to cancer clinical trial treatments for yourself or on behalf of someone else. 

Please Note: We do not assist with expenses such as rent,
mortgage, utility payments, childcare, pet care, food or insurance deductibles.

If you have questions please contact Lazarex Cancer Foundation directly for assistance with clinical trial travel expenses.

Download the CARE Financial Assistance Application

Descargue la Solicitud de Asistencia Financiera de CARE en español

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
 Financial Assistance Application for the Lazarex CARE program
Trial Verification Form for approved and enrolled Patients of Lazarex Cancer Foundation