Needs-Based Grant Application Form

Grant Application

EndoCare Fund — Financial Assistance for Endometriosis Care

Complete all required fields. Our team will review your application and follow up via email.

1 Applicant General Information

First Name*

Last Name*

Date of Birth*

Phone Number*

Street Address*

City*

State*

ZIP*

Email Address*

Primary Insurance*

Secondary Insurance (if applicable)

2 Medical Information

Diagnosis of Disease to be Treated*

Date of Diagnosis*

Diagnosing Physician / Practice

Physician / Practice Name*

Physician Phone*

Physician Address*

Surgical History

Procedure / Physician / Date for each surgery

Medication History (past 2 years)

Medication / Treatment / Date

3 Financial Information

Estimated Annual Family Income (before taxes)*

Number of Dependents in Household*

Are you receiving any other financial aid toward medical costs?*

Yes

Estimated Medical Expenses for Your Diagnosed Disease*

4 Summary Personal Statement

Summarize why you are applying for this grant and your hardship with the diagnosed disease. Include any personal or family circumstances that contribute to your financial need.

5 Supporting Documents

Upload each required document. These are submitted securely to our records system. Accepted: PDF, JPG, PNG.

Driver’s License* Choose File

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Insurance Card(s)* Choose File

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Medical Diagnosis Documentation* Choose File

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Personal Financial Statement* Choose File

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Last 2 Years Tax Returns* Choose File

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Proof of Income*pay stubs, benefit letters, etc. Choose File

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Detailed Personal Statement* Choose File

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Letter of Recommendation* Choose File

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6 Certification and Signature

I, [First Name] [Last Name], certify that the information provided in this application is complete and accurate to the best of my knowledge. I understand that providing false information may disqualify me from receiving financial assistance and could result in repayment of any funds received. I authorize the EndoCare Fund to verify the information provided and to contact my healthcare providers as necessary to evaluate my application.

I accept and certify the terms stated above*

eSign Here*

Draw Signature

Type Signature

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Your Signature:

Date*

Submitting your application…