Needs-Based Grant Application Form

Grant Application

EndoCare Fund — Financial Assistance for Endometriosis Care

We believe that all people, regardless of financial standing, deserve access to life-changing medical care. When it comes to treating endometriosis, sometimes surgical intervention is necessary. But due to current limitations with insurance providers in the United States, many of the best endometriosis specialist surgeons are out-of-network. This requires a payment from the patient that can be prohibitive. EndoCare Fund exists to help cover these upfront surgical costs, so that qualified applicants can receive the treatment they need.

Before applying, please note the following eligibility requirements and program terms:

Applicants must reside in the United States.
Surgeons and surgeries must be in the United States.
Applicants must have health insurance coverage.
Applicants must have consulted with a doctor who has deemed surgery medically necessary or advisable.
Applications are reviewed on a case by case basis to determine what percentage of fees can be covered.
EndoCare Fund covers out-of-network surgical fees, but we do not cover hospital stays, anesthesia, or any other associated surgical cost that can be paid for by insurance.
We do not offer financial assistance for needs other than private surgical fees at this time.

If you meet the above eligibility requirements, complete all required fields in the form below. 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* (enter "None" if not 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. If you have no surgical history, enter "None" in the field below.

Medication History (past 2 years)*

Medication / Treatment / Date. If you have no medication history, enter "None" in the field below.

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. All documents below are required to submit. These are submitted securely to our records system. Accepted: PDF, JPG, PNG.

Driver’s License* Choose File

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Insurance Card(s)*Please select all insurance-card files at the same time. Selecting one file and then selecting another will replace the first file. 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*Please select both tax-return files at the same time. Selecting one file and then selecting another will replace the first file. Choose File

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Proof of Income*pay stubs, benefit letters, etc. Please select all files at the same time. Selecting one file and then selecting another will replace the first file. 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…