Apply For Help

Pay It Forward Fund helps women who are struggling financially while being treated for breast and women’s cancers (cervical, ovarian, uterine) at North Memorial, Unity, Mercy, New River and Ridgeview Medical Centers in Minnesota. If you fit this criteria, we’re here to help! Please read our Pay It Forward Guidelines and submit our application.

Application for Financial Assistance

Name *

First

Last

Phone Number *

Street Address *

City *

State / Zip *

Birth Date - mm/dd/yy *

Email *

Cancer Center You Are Being Treated At: *

Name of Oncologist *

Current Treatment *

Chemotherapy Radiation Other

Other *

Circumstances Leading to Current Need *

I declare that the information on this application is true and correct, and hereby give my permission for my medical records to be obtained. *

YES

Electronic Signiture *

Electronic Signiture Date mm/dd/yy *