Circle of Hope Cancer Support Group
Supporting Cancer Victims and Their Families in Western Kansas
Home
Application for Financial Assistance
To apply for assistance, please fill out the following form. To be elligible for assistance, you must live in one of the following counties: Clark, Comanche, Edwards, Finney, Ford, Grant, Gray, Haskell, Hodgeman, Kearney, Kiowa, Meade, Ness, Seward or Stevens.
Maximum individual distribution is $1,000. The amount covered toward the expense will be determined by the Circle of Hope Board of Directors.
Patient Information
County of Residence
*
Select County
Clark
Comanche
Edwards
Finney
Ford
Grant
Gray
Haskell
Hodgeman
Kearney
Kiowa
Meade
Ness
Seward
Stevens
Name of Patient
*
First
Last
What language does patient speak?
*
English or Bilingual
Spanish Only
Address
*
Street Address
City
ZIP Code
Email Address
*
Date of Birth
*
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Home Phone
*
Work Phone
Employer (if applicable)
Retired
Yes
No
Contact Person Information
Must be a family member or close friend who seeks English.
Contact Person's Name
Relationship to Patient
Contact Person's Home Phone
Contact Person's Work Phone
Financial Assistance Categories
Assistance Requested
*
Medication expense for cancer-related prescriptions.
Expenses for medical services not wholly covered by insurance.
Mileage reimbursement for out-of-county travel expense.
Treatment Location
*
Travel Frequency
*
Daily
Weekly
Monthly
Other
Health Insurance
Is the applicant covered by health insurance?
*
Yes
No
Cancer Policy?
*
Yes
No
Deductible: individual/family
Type of Cancer
*
Agency Care Provider
Is the applicant being cared for by a home health group or nursing home?
*
Yes
No
Agency Name
*
Agency Phone
*
Agency Address
Street Address
City
ZIP Code
Physician Information/Verification
Physician Name
*
Physician Phone
*
Physician Address
*
Street Address
City
ZIP Code
Submit Application
Checking this box indicates that all information is true and accurate.
*
I certify that this information is true and accurate.
Name of Patient or Representative
*
Date
*
Date Format: MM slash DD slash YYYY