Fight the Good Fight, Inc.
Patient Co-Payments/Clinical Trial/Medical Relief
Application Form for Patients
Diagnosed with Primary Brain Tumors
Fight the Good Fight is a nonprofit 501(c3) organization dedicated to helping patients diagnosed with Primary Brain Tumors.
This program can help adults 18 and older pay for chemotherapy and targeted treatment drugs, clinical trial medication, blood work related to treatment diagnosis, PET Scan/MRI Scan/CT Scans related to the diagnosis, Medical Relief of hospital/ambulatory care related to treatment and diagnosis if you meet the qualifications and if we have funds remaining. There is never any cost to you. You can use any doctors and treatments you like-we will never ask you to switch.
In order for us to begin the process of qualifying you for assistance, please complete the enclosed application and return it to, Fight the Good Fight, along with verification of your household income and copies of your insurance card(s). Completed applications can be received via mail or via email. Details of Guidelines are on page two and three. Details of acceptable documentation and submission options are outlined on page four. Upon receipt of your completed application, we will contact your treating physician to verify your diagnosis and will determine if you are eligible for copayment assistance based on our program guidelines and available funding.
If you qualify and if funding is available, we will provide you with copayment assistance for one year from your approval date. After that year you may reapply for copayment assistance program.
To reiterate, you must fill out the enclosed paperwork, sign it and return it to Fight the Good Fight, along with your income documents and insurance cards in order to be considered for funding. Please understand that all approvals are based on available funding and are approved on a first-come, first-served basis. Receipt of an application does not guarantee funding.
If you should have any questions or need assistance filling out the enrollment forms please do not hesitate to contact us via email at email@example.com.
PO BOX 2574 | Huntersville, NC 28078 | 305-322-4519