Online Application for Assistance

A Woman Like You Foundation

Application for Assistance

A Woman Like You Foundation is a non profit organization, which is dedicated to assisting residents of the Louisville, Kentucky area

who are battling cancer, and who lack sufficient health insurance and/or financial resources.

Submit your online application by filling out the form below and clicking SUBMIT.

There is a second form to submit after this form.  It is the Authority to Release Hospital Records / Medical Information.

Be sure to complete that form as well and click submit.

If you have questions, contact us at (502) 608.7761 or (502) 802.3500

IMPORTANT!

You must digitally sign the releases at the bottom of each online form before sending us this application.

All information is strictly confidential.

Authority to Release Hospital Records

and/or Divulge Medical Information

Be sure to complete this form as well and click submit.

If you have questions, contact us at (502) 608.7761 or (502) 802.3500

IMPORTANT!

You must digitally sign the releases on this online form before sending us this application.

All information is strictly confidential.

Hospitals and Physician's below are hereby authorized to furnish and release to A Woman Like You Foundation *all information and records requested (regarding findings, treatment rendered, and opinions) as to my condition. The foregoing authority shall

continue in force until revoked by me in writing.

*A Woman Like You Foundation is a non-profit organization, which provides non-medical supplemental financial

assistance to cancer patients in the Louisville, KY area.