Application for Individual Financial Assistance

Criteria for Consideration of Financial Assistance:

Applicant must complete and submit the HNC Living Foundation Individual Application for Assistance.
Applicant must have a diagnosis of head and neck cancer confirmed by an oncology health care provider.
Applicant must demonstrate financial need and meet HNC Living Foundation’s income qualifications.
Applicant must provide electronic or physical documentation of their cancer diagnosis and financial documents. Additional records may be requested dependent on request type.

Required Documentation:

Pathology report documenting a head and neck cancer diagnosis.
Financial demonstration of need (current government benefit letter, paystubs, bank statements, or other financial income from last 30 days).
Failure to provide the documents listed above may result in a delayed approval. Applicants can upload the documents on-line during the application entry, fax to 913-498-9588, or mail to 8100 Newton, Suite 100, Overland Park, KS 66204.

Qualifying Cancer Diagnoses:

Oral Cavity (Mouth, tongue, palate, jaw, inner cheek)
Pharynx (Throat, tonsil)
Larynx (Voice box, glottis)
Salivary Gland
Nasal Cavity & Sinus
Thyroid
Upper third of the Esophagus
NOTE: Cancers of the brain, eye and skin cancers of the face and scalp do not qualify.

Eligible Expenses:

Copayments: If payment is required at the time of appointment. We also provide assistance with copayments for diagnostic imaging, such as PET and CT scans.
Dental, we are able to assist with dental treatment plans in states where we currently have active grant funding. Please feel free to reach out if you would like to verify eligibility of your resident state before applying.
Trach supplies, head garments and equipment not covered by insurance.
Prescriptions and over the counter medication related to head and neck cancer treatment. Must be prescribed by a doctor, NP or PA.
Lodging, if treatment is further than 50 miles one way and have 2 or more consecutive days of appointments.
Oral nutritional supplements and enteral nutrition (tube feeding) during treatment, prescribed by your doctor.

Not Covered:

Expenses unrelated to the diagnosis, treatment or recovery of head and neck cancer.
Household and living costs, such as utilities, rent, mortgage and groceries.
Medical and dental expenses incurred prior to the application submission date.
Personal and home maintenance expenses, such as car repairs or home modifications.
Health and dental insurance premiums, including Cobra payments.

Review of Applications and Payment of Grants:

HNC Living Foundation does not provide emergency approvals for applications. Our staff diligently reviews, approves and provides grant payments to vendors within 14-21 days, depending on the request.
Payment will be made directly to service providers or vendors for future services.
No cash payments will go directly to the patient.
Failure to provide supporting documentation requested by staff may result in longer application approvals or denial of applicant’s request.

Is the applicant under active treatment for head and neck cancer or have they been treated for head and neck cancer by an established oncologist? *

Yes
No

Eligible cancers include: Oral Cavity (mouth, tongue, palate, jaw, inner cheek), Pharynx (throat, tonsil), Larynx (voice box, glottis), Salivary Gland, Nasal Cavity, Sinus, Thyroid, Upper third of the Esophagus. *Please note, cancers involving the brain, the eye, the skin of the head and neck or the lower esophagus do not qualify.

Is the applicant's annual and/or household monthly income at or below the following levels for the past 30 days:

Household Size		Income Threshold
1		$31,300
2		$42,300
3		$53,300
4		$64,300
5		$75,300
6		$83,920
7		$97,300
8		$108,300

Income *

Yes
No

Patient Information

Preferred Title

Name *

First

Last

Date of Birth *

Gender *

Race/Ethnicity

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Mobile Phone

Email

Caregiver or Support Person Name

Caregiver or Support Person Email

Caregiver or Support Person Phone

Is the applicant currently or have they previously served in any branch of the armed service?

Yes
No

Medical Information

Physician's Name

Physician's Office Phone

Social Worker/Nurse Navigator Name

Social Worker/Nurse Navigator Phone

Social Worker/Nurse Navigator Email

Clinical Diagnosis *

Date of Diagnosis

Brief Description of Request

Types of Assistance Needed

Note: We do not provide assistance for utilities, housing, mortgage, rent, groceries, car repairs, home modifications or other costs not directly related to the treatment plan prescribed by the medical professional.

Funding Information

Coverage

Do you currently have dental insurance?

Yes
No

Number in Household

Annual income for all household members, current year

Annual income for all members of the household, prior year

Last 30 days of income for all members of the household

All sources – salary, disability benefits, pension, social security, unemployment benefits, etc.

Employment Status

Employed
Unemployed
Retired
Other

Have you received donations through personal fundraisers?

Yes
No
Unknown

May include GoFundMe, Facebook, or other charitable efforts

In order to expedite your application, please attach your income for the past 30 days and pathology report stating you have head and neck cancer.

Add Files (PDF, JPG, or PNG)

Click or drag files to this area to upload. You can upload up to 10 files.

Consent to Release Information

I do hereby authorize all hospitals, financial institutions and insurance groups to release to HNC Living Foundation, or its duly authorized representatives, any information deemed necessary to complete its investigation of my application for financial assistance. In addition, I do hereby authorize all hospitals, financial institutions and insurance groups to release to HNC Living Foundation, or its duly authorized representatives, any information or itemized statements that pertain to the diagnosis and treatment and related expenses. I further authorize HNC Living Foundation and its representatives to provide such information to those institutions as may be reasonably required. All consents given herein shall continue until such time as the undersigned provides notice of termination in writing.

In order for HNC Living Foundation, a not-for-profit organization, to advance supplemental financial support expenses in conjunction with the medical treatment of the patient the undersigned do hereby affirm as follows:

The undersigned is the patient.
The term “non-medical expenses” is understood to mean lodging, food, gas, parking and transportation for patients who require treatment and expenses incurred by the family of the above-named in conjunction with that patient’s medical treatment. Financial assistance will be provided with the use of said funds to be specified by HNC Living Foundation.
The undersigned further agrees to return any unused funds immediately to HNC Living Foundation so that those funds can be utilized by the organization to benefit other families.
The undersigned acknowledges and agrees to maintain records that will be made available to HNC Living Foundation upon reasonable request, detailing the expenditures made from the funds provided by the organization.
The information provided on the application form is true and correct to the best of my knowledge.

HNC Living Foundation reserves the right to distribute funds at its sole discretion. HNC Living Foundation may pursue restitution for grants if it is determined that the information submitted on the application is false.

When awarding a grant, HNC Living Foundation is not advocating for the specific health care providers or medical equipment suppliers, but only providing the funds to enable you to access the services and equipment. You acknowledge and agree that accepting a grant from HNC Living Foundation is strictly voluntary. Furthermore, you agree that you will be responsible for any choices you make regarding the medical care, equipment or supplies, or for the failure, malfunction, repairs or ongoing maintenance of any equipment obtained as a result of the grant of funds.

Applicant Signature

Clear Signature

Today's Date

Name of person completing application (if different from applicant) and your relation

Would you be willing to submit a short note of gratitude and/or a picture of yourself for our funders? Hearing directly from people like you helps our donors see the real-world impact of their support and is a critical part of our grant reporting.

Yes
No

How did you hear about HNC Living?