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LIVESTRONG™ SurvivorCare Form

The Lance Armstrong Foundation's LIVESTRONG SurvivorCare program is here to help you. We have partnered with the following three organizations to provide you with free, confidential, one-on-one support with your cancer-related needs.

To receive assistance:

  1. Review list of services we provide
  2. Complete the form and submit
  3. You will hear back from us within 1-2 business days.

If you need immediate assistance, please call us at 866.235.7205.
We are available Monday – Friday, 9-5pm ET (excluding holidays) View the holiday schedule.




* required information
LIVESTRONG SurvivorCare 
Fill out the following form for cancer support questions
I (the person submitting this form) am seeking services and/or information for:* Myself - I have cancer
Myself - a family member or loved one has cancer (we offer services for all who are touched by cancer - not only the person with cancer)
Patient/Client - I am a health professional
I prefer not to answer
First Name:*
Last Name:*
Birth Date:(mm/dd/yyyy)
Age Range:*
Gender: Female   Male  
Please select the racial and ethnic category or categories with which you most closely identify. Select all that apply:* African-American/Black
American Indian/Alaska Native
Asian
Caucasian/White
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Other
I prefer not to respond
Do you have children:* No
Yes, under 18 years of age
Yes, over 18 years of age
I prefer not to answer
Address Line 1:
Address Line 2:
City:
State:*
Province:
ZIP/Postal Code:*
Country:*
Best Form of Contact: Email
Phone
Postal Service
No Preference
Email:*
Phone:
Cell Phone:
Cancer type(s):*
State of Treatment: Newly diagnosed (has not begun treatment)
Currently in treatment (receiving chemo rounds/radiation/surgery/medications)
Finished with treatment (not receiving treatment or medications)
Long term survivor (has been out of treatment for 5+ years)
Chronic condition (undergoing adjuvant therapy as a preventative or ongoing procedure to contain the cancer)
Recurrance (cancer has come back or second cancer diagnosed)
Hospice/End of Life
Prefer not to answer/not applicable
Referred From:
I would like to get help with:* Coping emotionally with my cancer or with a friend/family member who has cancer
Joining a telephone or on-line support group (International Support is provided in English only)
Identifying bereavement resources/dealing with the loss of someone to cancer
Learning more about my diagnosis
Learning more about preserving my fertility
Learning more about cancer in general
Learning more about cancer symptoms and treating side effects (fatigue/nausea; vomiting/loss of taste/loss of hair)
Learning how to communicate better with my doctor/spouse/family/loved ones
Learning about resources for financial assistance
Handling debt and financial management issues as they pertain to your diagnosis
Getting access to medical treatments/medical devices
Assistance for uninsured or underinsured
Assistance with insurance denial/appeal
Handling employment discrimination/retention issues
Applying for federal/state programs such as Medicaid/Social Security/Disability/etc
Learning about your clinical trial options
Other
If other please explain:
Would you like to receive a free LIVESTRONG Survivorship Notebook? **: Yes
No
SurvivorCare Terms of Service:* By submitting this form, I agree to have the Lance Armstrong Foundation and/or one of the other LIVESTRONG SurvivorCare partners (CancerCare/Patient Advocate Foundation/Emerging Med) contact me about the resources checked above. I understand that my contact information is kept confidential and will be used for this service only.
If you have CIGNA/Care Allies insurance, may we share your information with them to contact you?: Yes - By checking you agree to have a representative of CIGNA/Care Allies cancer support program contact you about the resources check above
No
Type the characters you see in the picture below:*
Redraw Image
 
If you have CIGNA Insurance or Care Allies Health Services through your insurance carrier there may be additional resources/services to help you.

** If you are requesting a notebook, please complete your mailing address. We cannot deliver to P.O. Boxes.
        

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