Clinical Trial Verification Form 

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THIS SECTION BELOW MUST BE COMPLETED BY YOUR MEDICAL REPRESENTATIVE ONLY (Oncologist, nurse, doctor, social worker, or clinical trial coordinator, etc...)

If this form is being submitted to apply to the program, please make sure the patient has already submitted the patient financial assistance application found on our website (https://lazarex.org/helping-you/patient-assistance-forms/). This form is the second step to apply for the financial reimbursement program. Please select the 'New Patient Applying for Financial Reimbursement Program' option below. 


If you are already receiving trial reimbursement from Lazarex Cancer Foundation for your clinical trial participation, periodic verification is required to continue reimbursement. Please select the 'Approved Patient in the Financial Reimbursement Program' option below. 
Clinical Trial Address




8-digit number starting with 0

NAME AND TITLE OF MEDICAL REPRESENTATIVE COMPLETING THIS SECTION

*Incomplete forms cannot be accepted*

By submitting this form, I verify that the information provided is correct.