AMXT 1501 Patient Financial Assistance Application

ELIGIBILITY:

  1. Brain Tumor Patients enrolled in the Oral AMXT 1501 trial
  2. Families requesting assistance are unable to financially support the patient enrolled in the trial.
  3. Parents/Guardians requesting assistance must reside with a diagnosed child. 
  4. Patient is a primary resident of the United States.
  5. A family requesting assistance has not received assistance from The Brooke Healey Foundation, Reflections Of Grace Foundation, Lauren's Fight for Cure, or The Cure Starts Now within 18 months of application date. 

WHAT TO UPLOAD

  1. Letter from the Primary investigator indicating date of enrollment and patient's name.

EXTENT OF ASSISTANCE (IF QUALIFIED)

  1. Up to $15/day for parking
  2. Up to $150 per visit for mileage costs on Days 1, 8, 15, and 22 of each cycle
  3. If you live more than 150 miles from the study site and cannot drive to the site, up to $500 for airfare
  4. If you fly or drive to the study site, up to $207 per night for hotel costs, for up to 8 nights during Cycle 1
  5. Total cap of no more than $3,000 per patient in total.
  6. Not qualified if patient received reimbursement for these costs elsewhere and assistance is only valid while currently enrolled in the trial.
  7. Participants receiving direct reimbursement may be subject to 1099 federal tax filings

Consideration may be given to patients participating in "compassionate approval" or "expanded access" offerings of the trial for brain cancers.  Please contact us directly to discuss if grant options are available.

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