Panhandle Cancer Cure Foundation

Apply For Help

Name of Applicant:

Form Completed By:

Address:

Name:

City, State, Zip:

Address:

Phone Number:

City, State, Zip:

Email Address:

Phone Number:

Date of Birth:

Email Address:

Healthcare Professional:

Primary Physician:

Primary Diagnosis:

Date of Diagnosis:

Total Amount Requested:

1. How was this amount determined?

2. Briefly identify the need(s):

3. Have other resources been explored to meet the identified needs?    Yes No

If yes, please identify source (s):

4. Briefly describe the applicant’s situation (number in household, ages of household members, employment, marital status, etc):

5. How is the applicant’s health care paid for? (Medicare, Medicaid, District Clinic, VA, Insurance, CIDC, Self Pay)

6. Identify sources of monthly income and expenses.

Net Monthly Income

Monthly Expenses

Source(s)
(18 & older in household)

Applicant

Spouse

Expenses

Applicant

         Spouse

Salary/Wages

Rent/Mortgate

         

Pension

Food Expenses

         

Social Security

Utilities

         

Supplemental Income (SSI)

Heat/Gas

         

Social Security Disability

Electricity

         

Unemployment Comp.

Water

         

Veteran's Benefits

Telephone

         

Food Stamps

Cable

         

TANF

Insurance

         

Child Support

Life

         

Savings

Property

         

Stocks

Medical

         

Bonds

Auto

         

CD's

Installment Debt

         

Other Income

Medical Expenses (not covered)

         
     

Medication(s)

         
     

Physician and/or Hospital

         
     

Child Care

         
     

Other (specify)

         
           

Total of Both Incomes

Total Expenses

         

1. All information is true and accurate to the best of my knowledge.

2. I give my permission that this form can be shared with the program committe and board of directors if neeeded.

Signature:
                                                 (Please type your name)

 

Enter Security Code: