Physician Confirmation

for a Second Opinion Grant from the Sarcoma Alliance

This form supports the grant application for 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.

Physician Confirmation for the Second Opinion Consultation

In order to process a grant application by the patient named below for a grant from Hand in Hand: The Suzanne R. Leider Memorial Assistance Fund, this form must be fully filled out and signed by the physician providing the second opinion. The Assistance Fund strives to help sarcoma patients with support for non-reimbursed expenses directly associated with obtaining a second opinion from a sarcoma physician. Please note that we do not reimburse any out-of-pocket expenses related to the treatment of sarcoma.
Name of Patient*
Confirmation*
Please enter the patient's email or phone number.
Date of Patient's Second Opinion Consultation:*
The Sarcoma Alliance may need to contact you or your facility to verify the patient's application.
Consent*

Thank you for supporting your patient's application for a grant to help with their expenses for a second opinion consultation.

Hand in Hand: the Suzanne R. Leider Memorial Assistance Fund strives to help sarcoma patients with support for non-reimbursed expenses directly associated with obtaining a second opinion from a sarcoma physician.

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.