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.
6. Applicants must be currently in treatment for lung cancer.
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?*

YesNo
Have you already received a gas card?*

YesNo
If yes, how long ago?*
Applicant's Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
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?*

Less than $10,000$10,000 to $19,999$20,000 to $29,999$30,000 to $39,999$40,000 to $49,999$50,000 to $75,000$75,000 to $100,000$100,000 or moreOther
Please specify your ethnicity.*

Hispanic/LatinoNot Hispanic/Latino
Please specify your race.*

Native AmericanAsianBlack or African AmericanNative Hawaiian/Other Pacific IslanderWhite/CaucasianOther
Are you currently working while undergoing treatment?*

YesNo
If yes, have you had to reduce hours?*

YesNoN/A
If no, did you have to take temporary leave or quit?*

YesNoN/A
Have you ever missed treatment due to transportation difficulties?*

YesNo
Please describe your need for travel assistance.*
How did you hear about the gas card program?*

Cancer Treatment CenterPrimary Care PhysicianAnother Lung Cancer PatientFriend or Family MemberOnlineOther
What type of card is more beneficial for you?*

Gas CardRideshare
Which of the following gift cards would you prefer?*

BPExxon MobilUber (Rideshare)No Preference (BP or Exxon Mobil)
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*

ChemotherapyRadiationImmunotherapySurgeryTargeted therapyOther
Is the patient currently enrolled in any clinical trials?*

YesNo
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.*

Yes, they have given their consent
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