LYMPHEDEMA TREATMENT

FINANCIAL ASSISTANCE

APPLICATION FOR OUR LYMPHEDEMA SUPPORT PROGRAM

This application is for current members of our Wellness Challenge only.

If you found this page but have not yet signed up for the Challenge, please sign up using this link in order to be considered for our Lymphedema Support Program.

Otherwise, let’s get right to it!

Introduce yourself to us

Help us get to know . . .

First, what's your name? (required)

Please fill out the application form to be considered for support and resources through The Rivera Foundation.

First Name *

Last Name *

Nice to meet you!

We’re so glad you connected with The Rivera Foundation. Our mission is to support and uplift the lymphedema community, and we’re honored to get to know you on this journey.

So tell us a little about yourself and why you joined this program! *

We’re excited to connect with you!

If you're open to it, what areas of your life are most impacted by lymphedema right now?

No matter where you are in managing your lymphedema, we want to support you in finding or getting back to the things you love to do!

Thanks for sharing all of that!

Now that we have that information...

What kind of compress garments or supplies can we support you with? Select all that apply. (required)

(Please note that while our goal is to help everyone get exactly what they need, selecting the garments and supplies below does not automatically guarantee approval for any or all products. Thanks for your understanding!)

Lymphedema Blueprint Course

Ready made / off the shelf compression garment for day-time use

Custom made compression garment for day-time use

Ready made / off the shelf compression garment for night-time use

Custom made compression garment for night-time use

Bandaging supplies and/or bandaging alternative compression garment

I'm not sure, send help!!

Okay, got it!

To best support you, it’s helpful to know if you’re currently working with a lymphedema therapist. If not, that’s okay—just let us know where you are in your care journey. (required)

Yes!

I recently graduated from therapy, woohoo!

No, I need help finding one.

If you're currently working with a therapist or recently have, please share their contact information below so we can better support your care.

Include the first and last name of your therapist, their facility or clinic name, their phone number, and email address if possible. Not all therapists share their email addresses, so we understand if you can only give us their phone number right now!

Now that we’ve learned more about your lymphedema, we’ll ask a few questions about your financial situation to align with our nonprofit guidelines.(required)

Please answer as accurately as you can so we can consider your full application. We know lymphedema care can be costly, no matter your situation.

Why are you seeking financial assistance from Ninjas Fighting Lymphedema Foundation?

I don't have insurance and I can't afford compression garments/supplies on my own

I have insurance with a high deductible, co-pay or co-insurance and I can't afford compression garments/supplies on my own

I have insurance but my insurance doesn't cover the brand of compression my therapist is recommending or that I think I need and I can't afford compression garments/supplies on my own

I have insurance but I can't find any places that take my insurance in person or online and I can't afford compression garments/supplies on my own

I have insurance but the compression garments I need were denied by my insurance as experimental or not medically necessary and I can't afford compression garments/supplies on my own

We just need a bit more info.

What is your household’s average monthly income over the last 3 months?

We just need a bit more info. What is your household’s average monthly income over the last 3 months?

Income isn't everything, so let's make sure we get the whole picture. (required)

After all of your expenses each month, how much money do you have left at the end of the month for savings, fun money or unexpected costs and emergencies? Again, if it varies due to self-employment or seasonal work, please share the average of the last 3 months (even if it's a negative number and you've been relying on your hard-earned savings to get by). (If you are not using US Dollars as your currency, please either convert to US Dollars or tell us what currency you are using.)

Almost done—thanks for sticking with us!

We just need a few final details to contact you and update you on your application status.

Please type your name below to confirm that the information provided in this application is true, accurate and complete to the best of your knowledge and that you are the person who is the subject of the application or have been authorized by the person applying to act on their behalf. By typing your name below, you understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Clear

Email *

Phone

Address

Street Address

Where we can send packages securely should your application and supplies be approved!

City

State

Country

Postal code

And last but certainly not least...What's your date of birth? (required)

We love to celebrate birthdays in the Ninjas community! We also need it to help us apply for future funding.

Date of birth *

Please enter as MM/DD/YYYY. Thank you!!

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