How To Apply

Heartland Cancer Foundation is committed to a clear application process.

Patient or providers may complete the online application​ or print the application and mail the completed application to the foundation office. Heartland Cancer Foundation will review the application on a rolling deadline to approve or decline your submission.
 Once a determination has been made, you will be notified by mail.

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Step 1:

You are requesting financial help with gasoline, house payments, car payments and/or utilities for cancer care

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Step 2:

Patient qualification relies on the following eligibility criteria:

1. Currently a cancer patient and receiving cancer treatment
2. 
Reside in one of the following counties:

   Nebraska: Boone, Butler, Cass, Fillmore, Gage, Jefferson, Johnson, Lancaster, Nemaha, Otoe, Polk, Pawnee, Richardson, Saline, Saunders, Seward, Thayer and York


   
3. Patient income must be equal to or below 300% of Federal Poverty Level (see Income Requirements)
4. Must have been at least one year since you qualified for assistance from the Heartland Cancer Foundation
 and must have read and accepted the Grant Restrictions

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Step 3:

Gather information needed for the application

1. Patient Information
: First and Last Name
, Address
, Date of Birth
, Gender, 
Marital Status, 
Phone, 
Email address, 
Alternative contact
, Phone number
 and Language Preference

2. Provide One Proof of Income: Recent Tax Return, w-2′s, 2 most recent pay stubs, Medicaid verification
 (total household gross monthly amounts from all sources)
3. Number of miles round trip to and from cancer treatment

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Step 4:

This information may be completed by your oncology or radiation clinic:

1. Physician First and Last Name
2. 
Facility/Practice Name
, Address, 
Phone Number and Fax Number

3. Type of Cancer
, Number of monthly visits and 
Length of cancer treatment

Click Here To Download The Application