Patient Application

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“You have cancer” are the three words that no one wants to hear. We understand that cancer does not just affect the patient but also friends, family & loved ones and we want to help! Mikey’s Miracle Foundation, Inc. provides sustainable programs and support services that improve the quality of life for patients receiving cancer treatment and their families at an affordable amount or no cost at all.

Before applying, please carefully read and consider the guidelines below. A member of our Patient Services & Support team will review your application submission and follow up within 14 business days on next steps. Should you have any questions or concerns regarding the application process, please contact us at info@mikeysmiraclefoundation.org.

GUIDELINES: 

  1. Reside in the Baltimore Metropolitan area
  2. Be a diagnosed cancer patient and be in active treatment at the time of application
  3. Program enrollment is 1 year
  4. Diagnosis verification from medical oncologist required
  5. Money is disbursed directly to service providers




Name (required)

Date of Birth (required)

Address: Mailing Address, City, State and Zip (required)

Phone Number (required)

Best Time to Call (required)
MorningNoonEvening

Email (required)

Referral Source (required)

Type of Illness

Date of Diagnosis

Indicate Stage (if known)
IIIIIIIV

Other Medical Conditions

AREAS OF NEED (PLEASE CHECK ALL THAT APPLY) (required)
Early Detection Screening/PlanningIndividual & Family CounselingPastoral CounselingNutrition Services/Meal PlanningProfessional Cleaning ServicesTransportation Services

BRIEF SUMMARY OF INTEREST (Please provide a one paragraph summary on how you will you and your family can benefit from the foundation. A follow-up interview (phone or in-person) will be required after application submission for additional information.
(required)

UPLOAD YOUR MEDICAL RECORDS HERE