Harrington Cancer & Health Foundation - Grant Application (English)

Harrington Cancer & Health Foundation

(806) 331-2400 | www.hchfamarillo.org
Grant Application for Cancer Patients in Need of Support
Goal: To financially assist cancer patients who are financially stressed and are undergoing cancer treatments.

Eligibility: In order to be eligible for financial assistance you must have a diagnosis of cancer confirmed by an oncology health care provider and be in active treatment (chemotherapy/radiation) in the Amarillo Service Area. If your cancer diagnosis is not treatable in Amarillo, assistance may be provided. A note from your Amarillo oncologist or primary doctor must accompany your application.

Cancer Patients may apply for assistance in the following areas:
- Utilities (gas, electric, water)
- Mortgage / Rent
- COBRA Insurance premiums
- Gas Assistance (if traveling)
- Lodging Assistance (if traveling)
- Prescription Co-Pays at treatment center
REQUIRED for Application Processing
- Please include supporting documentation with application: copies of original bills/letter from landlord and income verification documents (3 paystubs).
Applicant's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Age
Local Oncologist
Primary Diagnosis
Date of Diagnosis

MonthDayYear
Date
Form Completed by: (Please fill out if other than applicant)
Name

First NameLast Name
Address
Phone Number
Please enter a valid phone number.
Email
example@example.com
Applicant/Family Member Signature

Clear
Date

MonthDayYear
Date
1. Briefly identify the need(s) (Include copies of bills you would like to be considered)
2. Have other resources been explored to meet identified needs?

YesNo
If yes, identify resources explore and if not, why?
3. How is the applicant's health care paid for? (i.e. Medicare, Medicaid, District Clinic, VA, Insurance, CIDC, Private Pay). If this is in regard to dental care, does the patient have dental insurance?
4. Briefly describe the applicant's situation -
Name and ages of individuals living in hoome:
Employment info:
Martial status:
Treatment status: (start date, type, estimated completion date)

Monthly Income (Sources of Income 18 and Older in household)

	Patient	Spouse/Other
Salary/Wages
Pension
Social Security
Supplemental Security Income (SSI)
Unemployment Comp
Veteran's Benefits
Food Stamps
TANF
Child Support
Savings, Stocks, Bonds, Cd's, etc.
HUD
Other

Total of Both Incomes
Monthly Expenses
Select one

MortgageRentOwn Home
Housing Expense
Food Expense

Utilities Expense

	$
Heat
Electric
Water
Telephone
Cable
Cell Phone

Total Utilities Expense

Insurance Premiums

	$
Life
Property
Medical
Auto

Total Insurance Premiums Expense
Installment Debt
Medical Expenses not covered by third party or insurance:
Medication
Doctor or Hospital
Total Medical Expenses not covered by third party or insurance
Transportation
Car Payment
Gas Expenses
Total Transportation Expenses
Child Care
Other (specify)
Total Expenses
Please submit a COMPLETE application with the required documentation (submit required documentation below)
- Email: mariibelrivera@hchfamarillo.org
- Fax: (806) 331-2401
- Questions: (806) 331-2400 (Select option 2 from the voicemail menu)
*All payments are made directly to businesses and not individuals. Assistance for gas is given in the form of gas cards.
Required Documentation Upload

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Cancer Survivorship Center

6600 Killgore Drive, #100

Amarillo, TX 79106

(806) 331-2400

FREE resources for cancer patients from the moment of diagnosis.

To explore all the resources offered through Harrington Cancer & Health Foundation and the Cancer Survivorship Center, please visit hchfamarillo.org
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Grant Application for Cancer Patients in Need of Support