Oneida Health Foundation Application for Support

Oneida Health Patient Support Application
The Oneida Health Care Fund provides grants of up to $500 to help patients with essential treatment‑related expenses such as medical bills, co‑pays, prescriptions, transportation, childcare, and similar needs. Eligible applicants must either receive care at Oneida Health or live in Madison or Oneida County. All applications are confidential and reviewed in accordance with HIPAA and applicable laws.
Applicant Information
Applicant Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Phone:*
Please provide the phone number where you can be reached M-F between 8am and 5PM.
Email:*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Diagnosis & Care Information
Are you receiving treatment through Oneida Health?*

YesNo
Date of Diagnosis*
What is your diagnosis?*
Patients must either live within the Oneida Health geographic radius or be receiving treatment at Oneida Health to be eligible.
If not treated at Oneida Health, do you reside in Madison or Oneida County?*

YesNo
Name of your medical provider:*
Provider's phone number:*
Please provide us with your physician's/provider's office phone number
Who referred you to the OH Foundation?*
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Type of Support Requested
What kind of support are you requesting?*

Medical bills related to current cancer treatmentInsurance co‑payments / prescription co‑paysTransportation expenses / gasChild care required to allow treatmentGarment assistanceGrocery/gas gift cardsOther
Other financial assistance needed:
How much assistance are you requesting?*
Briefly describe how the funds will be used (maximum $500/year during active treatment).

Previous Assistance
Have you received assistance from the Oneida Health Foundation in the past?

YesNo
If Yes... When?
If Yes... How much and for what?

Additional Information
How did you hear about our financial program?
Any special circumstances we should know about? (please attach an additional sheet if necessary):
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Applicant Information