Review our criteria for consideration of individual financial assistance
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:
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.
I confirm the information I have provided is accurate and true to the best of my knowledge.
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:
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.
*HNC Living Foundation will not sell or share your personal information; it will be kept in strict confidence. We only collect this information so we can contact you with questions or updates about your application.
Signing the media release form is not a requirement in order to receive assistance from HNC Living Foundation
I hereby give my permission to HNC Living Foundation and/or its representatives to use photographs, audio tape recordings, letters, information or videotape of myself and to use our names, information, these images or voice recordings in publications, slides, videotapes, motion pictures or on the Internet. I understand they will be used to inform families, volunteers, media, and the general public about HNC Living Foundation and its programs, services or events. I gladly give the authorization to support the efforts of HNC Living Foundation. I understand this authorization shall continue until terminated in writing.