Tomma Hargraves Gas Card Program

Tomma Hargraves Gas Card Program

Lung Cancer Initiative (LCI) offers the Patient Access to Care Gas Card Program to provide assistance to lung cancer patients while seeking treatment. LCI hopes this program will lessen the financial burden of patients receiving appropriate lung cancer treatment.
Please enter the access code below to continue with Care Gas Card Application

If you are a patient, please have your nurse navigator contact us for the access to code to fill out the application on your behalf.

If you do not have the access code please email Molly Heym at

mheym@lungcancerinitiative.org or call (919) 784-0410.
Access Code
Dear Applicant:

Below are the guidelines to assist you with the completion of the paperwork necessary to apply for a gas card.

1. All questions must be answered in order to be considered for fulfillment.
2. Applications must have a signature from the healthcare facility.
3. Once we receive applications, please allow up to 2 weeks for the application to be processed and mailed.
4. The gas card will be mailed to the patient's address. LCI will email the healthcare provider to notify when the gas card has been mailed.

Gas Card Guidelines

5. Applicants must be a resident of North Carolina or South Carolina.
6. Applicants must be currently in treatment for lung cancer that originated in the lungs.
7. Applicants may apply once every four months to receive a $50.00 gas card.
8. Each time an applicant applies, a new application must be filled out.
Today's Date

MonthDayYear
Date
Is this a returning application?
Have you already received a gas card?
If yes, how long ago?
Applicant's Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
Name of County
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What is your total household income each year?

Other
Please specify your ethnicity.
Please specify your race.

Other
Are you currently working while undergoing treatment?
If yes, have you had to reduce hours?
If no, did you have to take temporary leave or quit?
Have you ever missed treatment due to transportation difficulties?
Please describe your need for travel assistance.
How did you hear about the gas card program?

Other
What type of card is more beneficial for you?
Which of the following gift cards would you prefer?
Healthcare Facility Information
Name of Facility Where Treatment will be Received
Name of Healthcare Facility
Address of Facility

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Physician

First NameLast NameCredentials
Name of Healthcare Facility Contact Person

First NameLast NameCredentials
Email of Healthcare Facility Contact Person
example@example.com
Phone Number of Healthcare Facility Contact Person
Please enter a valid phone number.Format: (000) 000-0000.
Please estimate the number of miles roundtrip to treatment within the next 90 days using the calculation (miles per roundtrip x number of treatment = anticipated miles for 90 days)
Treatment Information
Diagnosis of Patient
Type(s) of Treatment Patient Will Receive
Is the patient currently enrolled in any clinical trials?
Signature of Patient
For providers completing this application on behalf of a patient: Please mark the checkbox indicating that the patient has given their consent for you to sign there instead.
Signature of Healthcare Facility Contact Person
Please verify that you are human:
Should be Empty:

Tomma Hargraves Gas Card Program

Healthcare Facility Information

Treatment Information