Verification of applicant diagnosis

Thank you very much for your assistance. Please feel free to contact us with any questions at grantinfo@lbbc.org or 855-807-6386, press #1.

This form must be completed by a healthcare provider. If you are not a healthcare provider, please do not complete this form. Please ask your provider to complete it for you. If this form is not completed by your healthcare provider, it could create a significant delay in your application process.

The Living Beyond Breast Cancer Fund provides one-time financial assistance grants to people receiving active treatment for early-stage breast cancer, or who are living with metastatic breast cancer, and experiencing financial concerns. In order to be considered for a grant, the applicant's healthcare provider must provide verification of breast cancer diagnosis.

Please complete this form on behalf of your patient. Demand for grants is very high. To expedite the review process for your patient, please submit this information as soon as possible.

By completing this form, I verify that my patient has been diagnosed with breast cancer.

Information about your patient applying for the grant

Patient legal name (No nicknames)(Required)

First Middle Last

Date of birth(Required)

Date of initial diagnosis(Required)

Our grant review process requires a stage to be provided. Please indicate your patient's stage at initial diagnosis:(Required)

Please describe:

Has the applicant been diagnosed with recurrent or metastatic breast cancer?(Required)

Yes, with stage 0 recurrence

Yes, with stage I recurrence

Yes, with stage II recurrence

Yes, with stage III recurrence

Yes, with metastatic breast cancer (stage IV)

Other stage recurrence

Please describe:

Please provide the recurrence/metastasis diagnosis date:

What subtype(s) of breast cancer were identified at diagnosis? Choose all that apply:

LBBC defines active treatment as surgery (lumpectomy or mastectomy only within 30 days of the close of the application date), chemotherapy, radiation, targeted therapies (ex. HER2 Targeted therapies), and immunotherapy. LBBC cannot consider applicants who completed treatment for early-stage breast cancer and current treatment is limited to preventative treatments such as hormonal therapy (Tamoxifen or Aromasin, Arimidex or Femara) or targeted therapies (Kisqali or Verzenio), for a grant.

Please specify which procedures/treatments your patient has completed since their diagnosis (check all that apply):(Required)

Please make between 1 and 10 selections from the choices below.

Please describe the other procedure/treatment your patient has completed:

Please specify which procedures your patient has had within the past 30 days (check all that apply):(Required)

Please make between 1 and 5 selections from the choices below.

If your patient had a lumpectomy or mastectomy in the past 30 days, please provide the date of the procedure.

Please specify which treatments your patient is having at this time (check all that apply):(Required)

Please make between 1 and 6 selections from the choices below.

Please specify which targeted therapies your patient is having:

Please describe the other treatment your patient is having at this time:

Please specify which procedures/treatments you expect your patient to have in the next 60 days. (check all that apply):(Required)

Please make between 1 and 10 selections from the choices below.

Please describe the other future treatment:

Information about the healthcare provider completing this form

Please provide your name and contact information

Name(Required)

First Last

Email(Required)

Title(Required)

Hospital/Practice name(Required)

City(Required)

State(Required)

Your direct phone number(Required)

Thank you for completing this form. If you have questions, please contact us at (855) 807-6386, press #1 or grantinfo@lbbc.org. Please note for your records the name of the patient(s) for whom you have completed a healthcare provider verification form. Forms are valid for 90 days from the date received.

Additional information about the Living Beyond Breast Cancer Fund can be found at lbbc.org/fund.

Verification of applicant diagnosis

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