Apply

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.

Step 1:

You are requesting financial assistance with transportation or housing during cancer treatment

Step 2:

Patient qualification relies on the following eligibility criteria:

Currently a cancer patient and receiving cancer treatment
 Reside in one of the following Nebraska counties:  Adams, Boone, Buffalo, Butler, Cass, Clay, Colfax, Fillmore, Franklin, Gage, Greeley, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Lancaster, Merrick, Nance, Nemaha, Nuckolls, Otoe, Pawnee, Phelps, Platte, Polk, Richardson, Saline, Saunders, Seward, Sherman, Thayer, Valley, Webster and York
Patient income must be equal to or below 300% of Federal Poverty Level (see Income Requirements)
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

Step 3:

Gather information needed for the application

Patient Information : First and Last Name , Address , Date of Birth , Gender,  Marital Status,  Phone,  Email address,  Alternative contact , Phone number  and Language Preference 
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)
Number of miles round trip to and from cancer treatment

Step 4:

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

Physician First and Last Name
 Facility/Practice Name , Address,  Phone Number and Fax Number 
Type of Cancer , Number of monthly visits and  Length of cancer treatment

Click Here To Download The Application