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Apply for a Second Opinion Grant

This form applies for a grant from Hand in Hand: The Suzanne R. Leider Memorial Assistance Fund. It is a program by the Sarcoma Alliance designed to reimburse out-of-pocket expenses related to a second opinion consultation with a sarcoma physician.

Application for a Grant from Hand in Hand: the Suzanne R. Leider Memorial Assistance Fund

"*" indicates required fields

Please complete the following form and include all relevant receipts for consideration.

This form applies for a grant from Hand in Hand: The Suzanne R. Leider Memorial Assistance Fund. It is a program by the Sarcoma Alliance designed to reimburse out-of-pocket expenses related to a second opinion consultation with a sarcoma physician. Please note that we do not reimburse any out-of-pocket expenses related to the treatment of sarcoma.
Date of Application*
Patient's Name*
Patient's Date of Birth*
Patient's Address*
Regulations require that we can send reimbursement grants only to addresses within the United States.
Patient's Email*
Date of Diagnosis*
Do you have health insurance?*
Date of Second Opinion Consultation*
Address of Facility*
Have you consulted with this physician before?*

Reimbursement Amount

You must submit the following information and receipts for consideration of grant funds. All receipts and supporting documentation MUST coincide with the specified date of the second opinion consultation. Please check all that apply and fill in the expenses on the corresponding lines.
May be copies of appointment logs, bills from your provider, statements from your insurance carrier, or receipts for airfare, meals, lodging, parking, etc.
Drop files here or
Accepted file types: jpg, png, doc, docx, pdf, Max. file size: 128 MB.
    Provide US dollar amount for non-reimbursed second opinion consultation.
    If you drove your own car, specify # of miles from your home to the facility.
    Provide cost of airfare, train fare, rental car, taxi, etc. (If patient is a minor, include amount for guardian also.)
    Provide amount only for patient.
    Provide amount only for patient. (If patient is a minor, include amount for guardian also.)
    Provide amount only for patient. (If patient is a minor, include amount for guardian also.)
    Provide US dollar amount.

    Patient Confirmation

    In order to process this application, this section must be fully filled out and must be signed by the patient/guardian.
    I confirm that:*
    (ALL boxes below must be confirmed.)
    Clear Signature
    Today's Date*
    Consent*
    How did you learn about Second Opinion Grants from the Sarcoma Alliance?*

    NOTE: For this application to be considered, the Physician Confirmation Form must also be completed.

    You can ask your physician to sign the form on your device during your consultation, or you can send the link to the form to their office for completion. Find the link on the Second Opinion Grants page.

    Thank you for submitting an application to Hand in Hand: the Suzanne R. Leider Memorial Assistance Fund.

    This Assistance Fund strives to help sarcoma patients with support for non-reimbursed expenses directly associated with obtaining a second opinion from a sarcoma specialist. Grants are awarded for eligible expenses up to the maximum award limit per patient for a period of one year from the date of the first application. The AF will award eligible applications based on available funds. Receipt of an application with qualifying expenses does not ensure that funding will be at the maximum level requested. Applicants will receive a letter of acknowledgement confirming receipt of application. Grants are reviewed and approved on a quarterly basis, and notification of award will follow.

    If you have any questions, please call 415.381.7236 or email info@sarcomaalliance.org.

    This field is for validation purposes and should be left unchanged.