Wish Fund - Eligibility Questionnaire

Have you been diagnosed with stage IV breast cancer?
(If no, you do not qualify for this program.)

What was the date of your Stage IV breast cancer diagnosis?
(Backed by medical documentation, provided later)

Cancer Stage:

First Name

Last Name

Date of Birth

Phone

NOTE: Please use the same phone number, if filling out more than one form.

Verify/Retype Email

Zipcode

City/State

Household members (Adults 19 / Children 18 and below)

Adults 19 : Children:

Do you have medical documents stating these dates (diagnosis date / remission date)? This is required.

Are you able to provide supporting documents (i.e. medical records, income verifcation, bills, etc) online as attachments with your application? This is Required.

Can you complete and upload the HIPAA Compliant Authorization (filled out by you) and Medical Information Form (filled out by a medical professional).

How did you hear about UBCF?

Which team member did you speak with?