Dear Patient:

Thank you for contacting Genesee Cancer Assistance, a community based, volunteer organization dedicated to helping patients and families in Genesee County who are facing a cancer diagnosis. Our mission is to improve the quality of life and diminish suffering through education, services, and by offering you financial support during this difficult time.

We are enclosing the necessary paperwork to be completedfor you to apply to Genesee Cancer Assistance. Please follow the directions below and return the forms in the envelope provided. Along with financial assistance, we also have free services available that you may be interested in such as our Simply Beautiful (wig & make up) Program, a support group or counseling. Feel free to call if you would like more information about these services or have questions on how to use our financial assistance.You may renew your application annually as long as you are still receiving treatment.

Directions:

1. Fill out the Financial Aid Application Form.

2. Fill out the Patient Information Release Form.

a. In the blanks fill in the name and the complete address of the cancer doctor treating you.

b.Sign and date the form

3. Return both forms in the enclosed envelope.(Please return this application within 30 days or

you will need to call and reapply to our program.)

Upon receipt of your application, your doctor will be sent a form to verify that you are currently in treatment. Once we receive confirmation back from your doctor, you are then eligible to receive assistance. This process usually takes 1-2 weeks. We will call you once we receive your paperwork from the doctor. We ask however, that you call our office at (585) 345-0417 if you have questions, need to make specific arrangements for reimbursement, or to request additional forms. The office hours are Monday – Friday, 9am-1pm. If need be, leave a message and we will return your phone call as soon as possible.

Sincerely,

Patient Services Coordinator

127 North Street, Batavia, NY 14020

Phone: (585) 345-0417 Serving residents of Genesee County

Fax: (585) 344-7483 who have a diagnosis of cancer.