Patient Aid Application – Frequently Asked Questions
The application is available for download on our website here. If you do not have access to a printer, please contact the Leukemia Texas office at 214-265-7393 and we can mail an application directly to you.
The only documentation that you need to submit is the application and a current photo of the patient. However, this application must be completed with all required signatures and information. Please note that if the application is incomplete, late, or not legible, the application will not be accepted – no exceptions.
If your application is accepted, you will receive notice from Leukemia Texas within 3 weeks of the application deadline listed at the top of your application in red. Please do not call to check the status of your application during the 3-week process.
The Leukemia Texas Patient Aid program is reserved for persons diagnosed with leukemia (ALL, AML, CLL, CML).
If your application is accepted, you may receive a grant of $1,250 in patient aid to assist with treatment costs and access to care. If you have already received a grant from Leukemia Texas in the past, we ask that you wait one year before resubmitting an application to be considered for additional aid.
You may submit your application either by mail, email, or fax *Please know that if the application is not legible, it will NOT be considered. Therefore, mailing and emailing is the preferred method.
Mail to: Leukemia Texas
4925 N O’Connor Rd.
Irving, TX 75062
Or Email to: email@example.com
Or Fax to: 214-265-8577 Attn. Program Manager
It is very important that the doctor, physician assistant, or nurse practitioner attest to the leukemia diagnosis and need for assistance through the Leukemia Texas Patient Aid program. In addition to your doctor’s signature, an additional member of the medical staff (i.e. Social Worker, Financial Advisor, Practice Manager) must sign the application. This requirement is to ensure that the applicant is in need of financial assistance due to the expenses incurred from having leukemia.
This request is optional so it is not required to complete the application. However, the reason we ask for you include a photo is so that in the event that you are selected to receive aid, we are able to put a face to the person who is benefiting from the Leukemia Texas Patient Aid. If you do decide to share your photo(s), DO NOT FAX the photo. (It is ok to fax the written application)
You must be diagnosed with leukemia and be under the current treatment of a licensed physician and you must be both a U.S. citizen and legal Texas resident.
Please feel free to contact our office at 214-265-7393 or email us at firstname.lastname@example.org.