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)

If you're filling this out for someone else, please enter their name in this section. Thanks!

First Name *

Last Name *

Nice to meet you!

We are so glad you signed up for our Wellness Challenge this round and are excited to support you in managing your lymphedema. At Ninjas Fighting Lymphedema Foundation, we love getting to know each and everyone in the lymphedema community. (required)

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

We're so excited to work with you!

Lymphedema affects everyone differently, both physically and emotionally. If you're open to sharing, could you tell us some of the areas of your life that are more challenging because of lymphedema right now? Are there any hobbies or activities that lymphedema is keeping you from enjoying?

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 Ninjas 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!)

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!

For your safety and in order to help you get exactly what you need for your lymphedema, we require everyone we support to be under the care of a lymphedema therapist. Are you currently working with one? (required)

Yes!

I recently graduated from therapy, woohoo!

No, I need help finding one. (We can support you in locating a therapist however please note that any co-pays or other fees required by your therapist are not covered by Ninjas Fighting Lymphedema Foundation)

If you are currently working with a therapist or graduated therapy within the last 30 days, please tell us how to get in touch with your therapist here:

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 know all about you and your lymphedema, we do need to ask some questions about your financial situation based on the rules and regulations of our non-profit organization.(required)

Your insurance and income information do not immediately qualify or disqualify you for support from Ninjas Fighting Lymphedema Foundation, so please answer as best you can so we can make sure we have all the information we need to consider your application as a whole! We understand that caring for lymphedema (and any other health issues you or your family may be dealing with) can be expensive no matter what your financial situation looks like on paper!

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 need a little more information to continue...(required)

What is the total monthly income in your household? If it varies due to self-employment or seasonal work, please share the average of the last 3 months.

What is the total monthly income in your household? If it varies due to self-employment or seasonal work, please share the average of the last 3 months. (If you are not using US Dollars as your currency, please either convert to US Dollars or tell us what currency you are using.)

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 to complete this application so far.(required)

We just need a few more details for you to complete so that we know how to contact you with any questions and to share the status of your application once we are in the review process!

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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