Enrollment/Online Application

Complete and Print Your Application Online

You or your Advocate can complete and print the COMMITMENT TO ACCESS^® application online. To view the enrollment application, you will need Adobe^® Acrobat^® Reader. If you do not have it, click here to download a copy. For help completing the application, call Commitment to Access at 1-8ONCOLOGY1 (1-866-265-6491).
Be sure to sign and date the "Patient Authorization to Release and Disclose Medical Information" section.
Your Advocate can also request an application by calling Commitment to Access at 1-8ONCOLOGY1 (1-866-265-6491).
Each application has a unique 9-digit identification number that serves as your Commitment to Access ID number for as long as you remain in the program. Because the application has a unique ID number, it may not be photocopied.

Strike through the patient ID on the application and write in your patient's ID in its place.