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

  • MM slash DD slash YYYY
  • ORDERING PHYSICIAN AND FACILITY INFORMATION

  • HOUSEHOLD INFORMATION

  • Please enter a number from 1 to 100.
  • REASON FOR FINANCIAL ASSISTANCE REQUEST

    I certify that the information I have provided in this form is accurate and complete. I authorize Caris Life Sciences to use my information to determine eligibility for financial assistance or as otherwise permitted by law. Submission of this form does not constitute approval or guarantee eligibly to receive discounted services. The guidelines for providing hardship assistance may change or the program may be discontinued without notice.

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