Patient Financial Assistance Form | Kickin' Cancer in Redwood County

Name(Required)

First Last

Date(Required)

Amount Requested(Required)

Birth Date(Required)

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Please provide a secondary contact person

Name

First Last

Phone

Preferred Contact Method

Diagnosis(Required)

Date of Diagnosis(Required)

Current Treatments(Required)

Chemotherapy

Radiation

Surgery

Hospice

Palliative Care

Bone Marrow Transplant

Lymphedema

Cording

Date of recent treatment(Required)

Stage

Name of Oncologist or Oncology Nurse(Required)

Phone

Clinic Name and Location(Required)

Medical facilities where you are receiving care: (list all hospitals, clinics, radiation centers, etc.)

Medical Facilities

Name

City

Phone

If you have any additional comments about your situation to share with us, please provide them.

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

Amount

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.

How did you learn about the Kickin’ Cancer Program?(Required)

Untitled(Required)

I have read and understand the KCS guidelines. I declare that the information on this form is true and correct to the best of my knowledge. I understand that all applications will be reviewed individually and that final determination will be made by the KCS committee. All information reviewed is confidential.

Statements for Payment(Required)

Drop files here or

Max. file size: 50 MB.

Signature(Required)

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.