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Patient Assistance Forms

**Due to the stay in place mandate for Northern CA, the Lazarex office will be closed through April 6th. We are working remotely, you may experience some delay, but we will get back to you. Thank you for your patience.** LEARN MORE

Patient Navigation Questionnaire

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

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

Financial Assistance Application

This document is for requesting Financial Assistance with out of pocket expenses associated with cancer clinical trial participation.  Use this form if you are requesting financial assistance 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 expenses or for help with clinical trial identification.

Trial Verification Form (TVF)

Use this document to verify cancer clinical trial status for Lazarex patients. 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.