Application for Assistance Form

Financial Assistance Policies & Guidelines

Eligibility Criteria

Applicants must:
• live in or receive treatment in our four-county service area (Benton, Madison, Carroll, Washington).
• have a confirmed cancer diagnosis; proof of diagnosis is required.
• demonstrate financial need related to a cancer diagnosis.

The following requests for assistance will be considered:

Short-Term Living Expenses
To be eligible for financial assistance for living expenses, applicants must be in active treatment or within one year of treatment completion. Active treatment is defined as chemotherapy (IV or oral), immunotherapy, radiation therapy, bone marrow or stem cell transplant, and/or surgery.
Examples of living expenses: rent, mortgage, utilities, homeowner’s insurance, car payment, and/or car insurance.

Travel & Lodging Costs
Travel needs, such as hotel and air fare, for out of town consultations or treatment.

Supplemental Fuel Costs
Prepaid gas cards are provided to patients for travel to cancer-related appointments. Fuel costs are calculated based on vehicle type and mileage. Fuel is supplemental, we do not typically cover the full cost of a trip.

Medication
Need for medication must be directly related to the cancer diagnosis. Payment is made directly to a pharmacy.

Dental Care
Need for dental care must be directly related to cancer treatment. Confirmation from an oncology health care provider is required.

Transportation
Rides to cancer-related appointments and treatment. Must live in our four-county service area or no further than 60 miles one-way from appointment location.

Emotional Support
Individual, couples, caregivers, and/or family members may access mental health counseling services to address cancer-related concerns.

*It is our goal to provide a response to assistance requests in a timely manner. Please allow one business day for medication requests and up to 7 business days for other financial assistance requests.

The mission of Hope Cancer Resources is to provide compassionate, professional cancer support and education in the Northwest Arkansas region today and tomorrow.

Our Financial Assistance Program is supported in part through partnerships with the Cancer Challenge, Delta Dental, Northwest Medical Auxiliary, Hope Cancer Resources Foundation, as well as corporate and individual donors

Name of Patient*

First NameLast Name

Preferred Name

Optional

Date of Birth*

MonthDayYear

Social Security Number

Gender*

Ethnicity*

Home Phone:

Cell Phone

E-mail

example@example.com

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

# of People in Household

Employer

Diagnosis-Cancer Type*

If Other, please specify:

Date of Diagnosis

Date

Treatment Types

ChemotherapyRadiationSurgeryOther

Date of last treatment or surgery

Date

Physician Name(s)

Vehicle Information:
Year: Make: Model:

Yearly Household Income*

Insurance-(Choose all that apply)*

Services Requested-(Choose all that apply)*

Please briefly describe how cancer has impacted you financially:*

If you are NOT a patient at Highlands Oncology, proof of diagnosis is required. Please upload a pathology report or letter from your physician.

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Application for Assistance

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