HCCS
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    Application For Assistance

    Step 1 of 2

    HCCS offers financial assistance to residents of Henry County Georgia with a cancer diagnosis. If you are not a resident of Henry County Georgia, please feel free to contact us via the contact form as we may be able to provide direction on other avenues of assistance. 

    Select all that apply.
    By submitting this application for assistance, I hereby authorize Henry County Cancer Services ("HCCS") to release my name to HCCS supporters, whose donations make this assistance program possible. This authorization for release of information is limited to just my name. I understand I may revoke this authorization at any time by submitting a written notice of revocation to HCCS. 
Submit

Step 2 of 2

In order to ensure proper and ethical distribution of funds, we require the following document to be signed by your attending physician. Please download, print, and attain the signature from your physician. Submit the completed form to HCCS and the process is complete. 
patapppage2.pdf
File Size: 115 kb
File Type: pdf
Download File

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