Attestation of Ongoing Care
A Patient Aid grant, up to $1,250, is requested from Leukemia Texas for the purpose of ensuring equal access to care which
includes: treatments, laboratory testing, physician examinations, counseling and psychosocial support, transportation, and
housing for the patient.
The information provided will be verified with the patient’s physician, nurse and/or social worker by a staff member of Leukemia Texas.
Disclaimer: The Attestation of Ongoing Care requires the information of two people from the physician’s office or clinic. Examples, physician, physician assistant, nurse, social worker, financial counselor or other admin within the office.
(Check all that apply)
Physician Name and Contact Information
Other Contact from physician’s office or clinic (Social Worker, Nurse, Physician Assistant, etc.)