Patient Assistance Application

GRANT RESTRICTIONS

1. Patient household must be up to 300% of Federal Poverty Line.
2. Mission Cancer Foundation will not provide any one individual with more than $500 of assistance per calendar year.
3. Assistance is awarded on a first come first served basis after confirming eligibility and subject to the availability of funds in the foundation’s financial assistance program.
4. Patients will not be eligible for assistance unless they meet the Foundation’s financial need eligibility criteria.
5. The foundation may ask at any time for further documentation to support a patient’s eligibility, including after any grant has been extended. Any falsification of an application is fraudulent and subject to potential criminal penalties and civil damages.
6. In all cases, the patient will already be under the care of a physician with an oncology treatment regimen in place at the time of application.
7. Grants are awarded to patients aged 18+.
8. Financial assistance will be awarded directly to assist with expenses (We do not reimburse; we pay creditors directly). Applicants must supply copies of the bill, late notice, mortgage statement or lease agreement as well as a payment address and phone.
9. An applicant for financial assistance from the Foundation shall automatically be disqualified from receiving assistance if he or she is a member of the Foundation’s Board of Directors, or a family member of such a director.  For this purpose, a “family member” shall include the director’s spouse, ancestors, children, grandchildren, great grandchildren, and the spouses of his or her children, grandchildren and great grandchildren.  Such term shall also include a trust, conservatorship, Uniform Transfers to Minors Act account or other beneficial arrangement for the benefit of a director’s family member.

GEOGRAPHIC REQUIREMENTS

You must be receiving active oncology treatment in or reside in the following Central Iowa counties to be considered: Adams, Adair, Appanoose, Audubon, Boone, Carroll, Cass, Clarke, Dallas, Decatur, Greene, Guthrie, Hamilton, Jasper, Lucas, Madison, Mahaska, Marion, Marshall, Monroe, Polk, Poweshiek, Ringgold, Story, Taylor, Union, Warren, Wayne, Webster.    

INCOME REQUIREMENTS

For families/households with more than 8 persons, add $16,140 for each additional person.

At the end of this application, you will be required to upload scans or photos of several documents.  If you are unsure of how to do this, please contact the Mission Cancer Foundation at foundation@missioncancer.com or 515-235-8368.

You will need to upload:

1. Financial Verification (Income Tax Return & most recent pay stub, or Social Security Award Letter if taxes not filed. If your current tax documents do not reflect your current income, please send proof of the current income, income tax return, and letter of explanation of the change.)
2. Expense Verification (copies of bills needing payment assistance)
3. Health Statement signed by a member of your medical care team.

If the above file does not load (usually doesn't work on smartphones), please contact the Mission Cancer Foundation at foundation@missioncancer.com or 515-235-8368 to receive a copy.

When a patient completes an application, the patient is submitting and disclosing to Foundation personal health and other individually identifiable information.   If you are submitting or providing information to us electronically, you are doing so at your own risk.  The Foundation cannot guarantee the privacy of personal information you transmit over the internet or that may be collectable in transmit by others.

By submitting and completing an application for financial assistance you agree the Foundation may use and disclose the information you provide for its lawful purposes including but not limited to (a) determining your eligibility; (b) providing grant funding, and (c) the Foundation’s internal administration.  The Foundation is not a “covered entity” as defined by HIPAA and information submitted by you in connection with the application is not protected by or subject to HIPAA. 

The Foundation will, however, endeavor to protect the confidentiality and security of the information you submit by implementing commercially reasonable policies to safeguard and protect your personal information and will comply with federal and state consumer privacy laws to the extent applicable to the Foundation.  Despite the attempt to protect such information, the Foundation cannot guarantee that there will be not be an unauthorized use or disclosure. If any unauthorized use of disclosure is brought to the Foundation’s attention, the Foundation will attempt to contact the patient at the last address provided in an application.

By clicking "Next," you acknowledge and understand the above.