Apply For Assistance

Complete the following two steps to apply for assistance from Shirley’s Way:

1. Have your physician fill out the Physician’s Form and have them email it to

2. You fill out and sign the HIPAA Form and Patient Assistance Form, then email them both back to

Once all forms are submitted, we will then review, and make a determination.

    Are you still receiving a salary from the employer listed above?

    Is anyone in your immediate family helping you financially?

    Has anyone held a fundraiser for you?

    Publicity Release
    I agree to have my story and photograph in the media which will include our website, Facebook as well as local and national media.Please do not use my photo or story, I understand this may limit the resources available to help me financially.

    Have you or are you receiving financial assistance from another source?

    Terms and Conditions* (A copy of the Terms and Conditions is located here)
    I AGREE to all of Shirley's Way terms and conditions.
    HIPPA Form*
    I authorize Shirley's Way and all their representatives along with my physician to receive medical information. (Please fill out, sign and return HIPAA Form found above to

    I AGREE that everything on this Application is completely true to the extent of my knowledge.

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