Patient App

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Application For Assistance

Step 1 of 2

* Indicates required field

Are you a new applicant or applying for assistance renewal? *

New Applicant Applying For Renewal

Applicant Name *

First

Last

Date of Birth *

Applicant Address *

Line 1

Line 2

City

State

Zip Code

Country

Applicant Primary Phone *

Applicant Email *

Type of Cancer *

Type Of Assistance Requested *

Medical Bills (reimburse) Wigs/Turbans/Prosthetics (reimburse) Medications (reimburse) Mileage (reimburse) Cancer Resources Other

Select all that apply.

For Referral Purposes Only, Please Indicate If You Are Currently Covered By Any Of The Following *

Private Insurance Medicaid Medicare Veteran Other

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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