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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 assistance@shirleysway.com

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

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

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

    Is anyone in your immediate family helping you financially?
    YesNo

    Has anyone held a fundraiser for you?
    YesNo

    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?
    YesNo

    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 info@shirleysway.com)

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

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