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Cancer Support
Home > Form for CIGNA Customers

NOTE: THIS FORM IS NOT FOR WRISTBAND QUESTIONS.
If you have questions about LIVESTRONG wristband orders or the LIVESTRONG Store, please visit the Shopping FAQ or call 1-877-WEARYELLOW. 

LIVESTRONG™ SurvivorCare Form (CIGNA)

Please fill out the following form to receive information about your diagnosis or about LIVESTRONG SurvivorCare Services.

View a list of some of the services offered through LIVESTRONG SurvivorCare.

We currently provide financial assistance for treatment-related expenses to people living in the United States. International service is provided through participation in an online support group. At this time the service is only offered in English.

Please use this form if CIGNA is your insurance provider or if your health benefit plan uses Care Allies for medical management services. If you use a provider other than CIGNA or Care Allies, please fill out the appropriate form.

* 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
I am over 18 years of age (Services can be provided for those under the age of 18, however parental consent will be required):* Yes
No
First Name:*
Last Name:*
Age Range:*
Birth Date:(mm/dd/yyyy)
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:
Business Phone:
Cell Phone:
My Connection to Cancer:* I have or had cancer
Family member or Spouse or Partner
Caregiver
Friend or loved one
Healthcare provider
Health professional
Know someone with cancer
No connection
I prefer not to respond
Other
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:
Who is your insurance provider?:* Aetna
Blue Cross/Blue Shield
CIGNA
Medicare
Medicaid
United Healthcare
WellPoint
Other
I don't know
Prefer not to answer
No insurance coverage
If this is on behalf of someone with cancer, who is their insurance provider?:* Aetna
Blue Cross/Blue Shield
CIGNA
Medicare
Medicaid
United Healthcare
WellPoint
Other
I don't know
Prefer not to answer
Have you or the person with cancer contacted the insurance provider about additional services and oncology coverage?:* Yes
No
Prefer not to answer
If you have insurance other than CIGNA, does your health benefit plan use Care Allies for medical management services?:* Yes
No
Prefer not to answer
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
Other Comments:
SurvivorCare Terms of Service:* By submitting this form, I agree to have the Lance Armstrong Foundation and/or one of the other LIVE<b>STRONG</b> 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.
Type the characters you see in the picture below:*
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** If you would like to receive a Survivorship Notebook, please be sure to include your mailing address (no P.O. Boxes). You should receive the Notebook in approximately ten days.

As a CIGNA/Care Allies member, you have access to the CIGNA/Care Allies cancer support program in addition to the services provided by the other LIVESTRONG SurvivorCare partners (CancerCare, Patient Advocate Foundation, EmergingMed) and the Lance Armstrong Foundation.  You will be referred to the appropriate LIVESTRONG SurvivorCare partners by agreeing to one of the above choices.
        

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