Consult with doctor

There are two ways to apply: a direct referral from your local cancer treatment facility or applying for assistance on your own.

A direct referral from a local cancer treatment facility will include:

  • A Request for Financial Assistance Form will be filled out by a staff member on behalf of the patient.
  • A copy of the bill or invoice that needs assistance will need included with form.
  • The completed form and all included documents will be sent via fax, email or mail to our office.

The process for applying without the help of your local cancer treatment center is a similar process:

  • The patient needs to complete the Request for Financial Assistance Form.
  • A note from the treating physician that includes the diagnosis and date of diagnosis on an official letterhead will need included.
  • A copy of the bill or invoice patient is seeking assistance for will need included.

Once approved the patient will be contacted and payment process will begin.

Request for Assistance Form