Serving the Long Island communities of Carle Place, Garden City, Hempstead, East Meadow, Mineola, Westbury and Uniondale.
Stay In Touch...
Sign up for our email alerts
email address
Name:

Address:

City:                                                                State:                   Zip:

Number of years at this address:

Main Phone:

Business Phone:

Cell Phone:

Email Address:

Age:                         Date of Birth:

Marital Status:          Married           Single

If Married, Name of Spouse:

Children:          Yes              No

Number of Children:                 

Children's Ages (please separate with comma):

Treating Physician Name:

Address:

City:                                                                 State:                     Zip:

Phone:

Diagnosis:

Treatment:

Special Medical Needs or Other Considerations:


Please list in order (1,2,3...) of preference the services that you are interested in*:


          Reimbursement for travel to/from medical appointments

          Emergency financial assistance

          House cleaning

          Reimbursement for child care

          Assistance with obtaining wigs/prosthesis

          Massage therapy

          Support group

          Individual counseling

          Prepared meals

          Other, please explain:

*Subject to maximum amount and availability per qualified applicant.

All services provided are subject to availability and prior approval by the Mid-Nassau Lend a Helping Hand Program and subject to maximum amount per qualified applicant.

         I understand and agree that no promises or assurances whatsoever have been made to me by any representative of  Mid-Nassau Lend a Helping Hand regarding the requested program.

         I understand and recognize that the granting of any service and the participation of any person in the program is contingent upon approval by the Mid-Nassau Lend a Helping Hand program, as well as, compliance with all conditions , qualifications and restrictions designed by the Mid-Nassau Lend a Helping Hand Program.

         I certify that the above information is true and correct.

In order to receive assistance you must have your Doctor fill out the release form above. Please click on form to download a PDF version, have your Doctor complete and then fax or mail to us.
Click On Form Below for PDF Version
Click on form above for a PDF version of our Application For Assistance.
Home  |   Application Center  |  Events  |  Contact Us
Application For Assistance

You can apply for assistance from Mid-Nassau Lend A Helping Hand by completing the online application below or by downloading the PDF application version to the right. If you use the PDF application please fully complete the application and mail to: Mid-Nassau Lend A Helping Hand, P.O. Box 292, Amityville, NY 11701 or fax completed application to: (631) 789-2069. The online application is transmitted to a secure database server to ensure your privacy. If you complete the online application below you will still need to complete the physician's authorization form - see instructions below. Once we receive your application you will be notified of your request status and our decision.

To qualify for assistance you need to:

  • Submit a Doctor's confirmation showing current treatment for Breast Cancer.
  • Be a resident of Hempstead, Westbury ,East Meadow, Garden City, Uniondale or Mineola
  • Sign the confidentiality release form

It is our wish that we can be a supportive and caring resource for you. Please feel free to contact us anytime at (631) 789-2068.


Copyright © 2009  Mid-Nassau Lend A Helping Hand, Inc. - All Rights Reserved   P.O. Box 292, Amityville, NY 11701        631.789.2068