VSF Patient Relief Fund

The Vasquez Sarcoma Foundation offers a financial assistance program to help alleviate the financial burden that can accompany a sarcoma diagnosis. Applicants can receive aid to help with essential costs such as medical bills, gas, parking, and food. The foundation may make direct payments on medical bills. To be considered for assistance, applicants must provide proof of their sarcoma diagnosis.

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Download HIPAA Authorization, fill out, sign and submit with other required documentation below.

Apply for The VSF Patient Relief Fund Assistance

All Fields are required.

Patient First name

Patient Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Date of Birth

Month

Day

Year

Date of Diagnosis

Month

Day

Year

Sarcoma Type

Treatment Status

Oncologist First/Last name

Oncologist Phone

Oncology Center Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Please provide a brief summary of your diagnosis.

If accepted, what do you intend to use the financial assistance for?

Please upload the following files:

Proof of Sarcoma Diagnosis

Proof of Recent Income (Pay Stub/Tax Return)

Proof of Active Treatment or Past Treatment

Filled/Signed HIPAA Authorization

File upload

By signing, you are affirming that all the information provided is true and accurate to the best of your knowledge.

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Confidentiality Statement

The Vasquez Sarcoma Foundation is committed to protecting the privacy of all applicants. We understand that the information you provide is sensitive and personal.

All information submitted in this application, including your financial details and protected health information (PHI), will be kept strictly confidential. It will only be accessed by authorized staff members of the Vasquez Sarcoma Foundation who are directly involved in the review and approval process of financial assistance applications.

We will not sell, rent, or share your personal information with any third parties, except as authorized by the HIPAA form you sign or as required by law. We take all reasonable measures to ensure the security of your data, whether it is in a digital or physical format.

By signing the application form, you acknowledge that you have read and understood this confidentiality statement.