Skip to main content

Caring Breaths Lung Health Expenses Application Form

1. Contact Information

2. Lung Health Expense Receipts

Attach a copy of the lung health related receipt(s) you are requesting financial reimbursement for.

3. Support Documentation

People with lung disease and/or primary care givers applying for Caring Breath’s will require a referral form from a health care provider.

Medical: Health Care Provider Referral Form

Upload a copy of the documentation from a health care provider stating that you or someone you are caring for requires the above request. Your health care provider can also fill out the fillable PDF template below and email it to us directly at Some examples of health care providers that can provide a letter of support includes but is not limited to; Doctors, Nurse Practitioners, Nurses, Social workers, Physiotherapists, Pulmonary Rehabilitation Exercise Therapists, Certified Respiratory Educators, Respiratory Therapists, Pharmacists etc.

Download the Health Care Provider Referral Form

OR submit support document below.

4. Income Verification

What is your net disposable income? (monthly income after taxes) Choose range that applies to you.

5. Other Financial Support

Select any other organizations you have received financial support from to help cover related costs.

Help us do as much good work as possible by letting us know where you heard about our Caring Breaths Financial Assistance Program:

Optional: Other Information

You may use this field to provide any other information you feel is relevant or important to your application.

To find out more visit or If you have any questions about our Caring Breaths program, please email