Application for Assistance

A Woman Like You Foundation

Application for Assistance

A Woman Like You Foundation of Kentuckiana, LLC 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 application by downloading, printing and filling out the form below by clicking the pink box below.

Included in this application is an Authority to Release Hospital Records and/or Divulge Medical Information. 

Be sure to complete that section as well

If you have questions, contact us at (502) 608-7761 or (502) 802-3500

IMPORTANT!

You must sign the releases at the bottom of each 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 of Kentuckiana, LLC *

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 of Kentuckiana is a non-profit organization, which provides non-medical supplemental financial

assistance to cancer patients in the Louisville, KY area.