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 (paystubs, bank statements, or government benefit letter 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 Cancers
Salivary Gland Cancer
Throat Cancer
Upper Esophageal Cancer
Nasal & Sinus Cancer
Thyroid Cancer
Laryngeal Cancer

Eligible Expenses:

Co-pays and deductibles
Dental care (pre-treatment and post-treatment)
Travel costs for appointments related to treatment.
Doctor ordered medical supplies and equipment not covered by insurance
o Prescriptions related to head and neck cancer treatment. Must be prescribed by a doctor, NP or PA.
Oral nutritional supplements and enteral nutrition (tube feeding) during treatment

Not Covered:

Expenses not related to head and neck cancer treatment or recovery
Expenses that can be paid for through other community resources (i.e., emergency assistance funds for rent or utilities, food pantries)
Debt reduction, past due medical/dental bills, or costs incurred BEFORE application submission date
Home modifications

Review of Applications and Payment of Grants:

Requests of less than $2,500 will be reviewed and financial aid determined within 21 business days of receipt of completed application and supporting documents.
Requests over $2,500 will be reviewed by HNC Living Foundation’s Grant Committee and financial aid determined within 30 days.
HNC Living staff may adjust this timeline based on funds availability and volume of patient applications.
Payment will be made directly to service providers or vendors.
No cash payments or refunds 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.

By submitting an application, the applicant acknowledges HNC Living Foundation does not provide emergency services. The staff makes every effort to review applications in the given timelines listed above, however some approvals may take longer dependent on the, complexity of the applicant needs.

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

Is the applicant's annual and/or monthly income (minus out-of-pocket medical expenses) at or below the following levels for the past 30 days:

Household Size		Income Threshold
1		$37,650
2		$51,100
3		$64,550
4		$78,000
5		$91,450
6		$104,900
7		$118,350
8		$131,800

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

Funding Information

Coverage

Do you currently have dental insurance?

Yes
No

Number in Household

Annual household income, current year

Annual household income, prior year

Last 30 Days of household income

All sources – sasalary, pension, government benefits, etc.

Last 30 Days of out of pocket medical expenses

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

Today's Date

Name of Person Completing Application

Are you willing to submit pictures if requested for HNC Living Foundation's reports to funders?

Yes
No

How Did You Hear about HNC Living?