Patient Financial Assistance Form

Birth Date(Required)
Please provide a secondary contact person
MM slash DD slash YYYY
Current Treatments(Required)
MM slash DD slash YYYY
Medical facilities where you are receiving care: (list all hospitals, clinics, radiation centers, etc.)
Medical Facilities
This may help us when reviewing your application. If eligible, you are able to receive up to $1,500 per calendar year on covered expenses.
Bills for Payment(Required)
Company Name
You may request all funds to be paid to one company. You may also request the funds be split. For example: $500 for utility, $700 for heating & $300 for phone. KCS will send payments directly to each location on your behalf. If there is credit, the company will apply the extra for next month’s bill.
Drop files here or
Max. file size: 50 MB.

    How long does the review process take?

    Completed applications are reviewed as they come in. All applications are reviewed individually, with the final decision being made by the Kickin' Cancer Support (KCS) Committee. Information you share with us is confidential. If approved, a confirmation letter with a copy of payment made will be mailed to the applicant. If the application is denied, a letter of explanation will be sent, and if further information is needed it will be noted in the correspondence.

    Please allow about three weeks for the financial assistance check to be processed. A check will be issued and mailed directly to the creditor. A check cannot be made out to an individual. We are not able to process online payments.

    The KCS Committee reserves the right to make exceptions to the guidelines with the exception of providing funds exclusively to cancer patients.

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