Financial Assistance Request Form

Carrying the financial load of cancer care can be stressful at times. As part of your care team, Caris Life Sciences® is dedicated to ensuring that every cancer patient has access to the best possible treatment. While Caris molecular testing is covered by most insurance plans, we have additional financial assistance programs that provide added financial flexibility for patients. Caris’ Compassionate Care Program assists uninsured patients who may not be able to afford out-of-pocket costs associated with our molecular profiling test.

Patient Information

Name:

First*

Middle

Last*

Date of Birth*

Phone*

E-Mail

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Ordering Physician and Facility Information

Office / Institution Name*

Ordering Physician*

Physician Phone

Physician E-Mail

Household Information

Total Annual Gross Household Income*

Please enter a number between 1 and 150000.

Number of Persons in the Household (including self)*

Please enter a number between 1 and 100.

Patients at the center of everything we do