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Thank you for your interest in Cancer Care Services! This form gathers all the information we need to give you help quickly. We have financial services like helping pay for medications or transportation and non-financial services like social events with other people impacted by cancer.
If you need help filling out this form or need to give us documents in-person, please call us at 817-921-0653 to set up an appointment. We do not accept walk-in appointments.
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You can save this form if you need more time to work on it.
Since you do not live in Tarrant County, we cannot give you financial services, but we can still help you! You can keep filling out this form, but you can only get non-financial services.
You can also fill out our shorter "Contact Us" form. Tell us what kind of help you are looking for and one of our social workers will reach out to discuss resources you might be eligible for.
Link to Contact Us Form: https://form.jotform.com/212014237264041
We ask for demographic information because we want to make sure that we are helping everyone. The organizations that fund us also want us to have this information. If you are uncomfortable answering a question, select "Prefer not to Say" or "Decline to Answer".
Demographic information is not used to make eligibility determinations.
Cancer Care Services defines homelessness as not having a permanent place you can call your own to sleep. This includes staying with friends for a short time or living in a car/shelter.
SEE BELOW FOR EXAMPLES
Robert Paschal, Age 59, $3250 from Work
Julius Hemphill, Age 26, $1236 from Long-Term Disability
Reby Cary, Age 17, No Income
The applicant/patient receives Monthly Income in Dollars* per month from Income Source Alimony Payments Armed Forces Income Child Support Employment/Job/Work Family Support Foster Care Payments Long Term Disability Other No Income At This Time Pension Public Assistance Rental Property Income Retirement Savings/401K Short Term Disability Social Security-Disability (SSDI) Social Security-Retirement (SSR) Social Security-Supplemental Income (SSI) Tax Refund TANF Unemployment Benefits Veteran's Compensation Worker's Compensation *
Household Member Name, Relation to Applicant* receives Monthly Income in Dollars* per month from Income Source Alimony Payments Armed Forces Income Child Support Employment/Job/Work Family Support Foster Care Payments Long Term Disability Other No Income At This Time Pension Public Assistance Rental Property Income Retirement Savings/401K Short Term Disability Social Security-Disability (SSDI) Social Security-Retirement (SSR) Social Security-Supplemental Income (SSI) Tax Refund TANF Unemployment Benefits Veteran's Compensation Worker's Compensation *
Household Member Name, Relation to Applicant receives Monthly Income in Dollars per month from Income Source Alimony Payments Armed Forces Income Child Support Employment/Job/Work Family Support Foster Care Payments Long Term Disability Other No Income At This Time Pension Public Assistance Rental Property Income Retirement Savings/401K Short Term Disability Social Security-Disability (SSDI) Social Security-Retirement (SSR) Social Security-Supplemental Income (SSI) Tax Refund TANF Unemployment Benefits Veteran's Compensation Worker's Compensation
Attention: Completing this section does not guarantee financial assistance from Cancer Care Services. You must provide us all the information and documents we are asking for before assistance is given. You can submit this application without all the documents if you need time to gather them.
Cancer Care Services only covers the cost of health insurance. Vision, Dental, FMLA, STD/LTD, Life, Cost-Share, and Supplemental policies are not covered by this service. Medicare, Medicaid, and Tricare premiums are not covered by this service.
Documents Required
We can give nutritional supplements (ex. Boost Plus, Isosource 1.5) for free if you meet any of the following:
You must tell us your dietitian's contact information (name, phone number or email). If you are approved for services, your social worker will reach out to the dietitian.
*Head and neck cancers are reviewed on a case-by-case basis by Director of Programs.
We are sorry, you are not able to receive nutrition help from us.
Abbott Nutrition might be able to help you with getting some nutrition. Visit this link: https://www.pathwayreimbursement.com/patient.html or call 855-217-0698 to see what nutrition they can help with. If you have been prescribed a different kind of nutrition, ask your dietitian if they can write a new prescription for one that Abbott Nutrition does help with.
SNAP (food stamps, Supplemental Nutrition Assistance Program) also might be able to help you cover the cost. Call 211 and ask for help filling out a SNAP form. Or visit: https://www.yourtexasbenefits.com/Learn/Home
We can help you get to some of your treament appointments by giving you:
Please note:
As of January 2024, our Emergency Funds are PAUSED. Please continue with this application. We will be able to provide you with our other services until Emergency Funds are resumed.
Cancer Care Services can cover:
Cancer Care Services cannot cover:
Below, you will give us copies of your bill(s) and provide information on how we could make a payment on your behalf. Bills must meet the following criteria:
Funding is subject to availability.As of January 2024, our Emergency Funds are PAUSED. Please continue with this application. We will be able to provide you with our other services until Emergency Funds are resumed.
Please give us proof of disconnection or risk of reposession/eviction.
Tarrant Area Food Bank has a list of food pantries in North Texas. Visit: https://tafb.org/find-food/ or call 817-857-7100.
At times, Cancer Care Services may be able to provide grocery (ex. Walmart) cards.
I am asking for help with Type of Bill (Electric, car note)* for Amount ($)* from Name of Company/Vendor* . The person who is responsible for the bill's phone number is Phone Number*
I am asking for help with Type of Bill (Electric, car note) for Amount ($) from Name of Company/Vendor . The person who is responsible for the bill's phone number is Phone Number
I am asking for help with Type of Bill (Electric, car note) for Amount ($) from Name of Company/Vendor . The phone number on the account isPhone Number
You cannot give us the exact same bills (ex. your May electric bill) that you gave to other agencies or non-profits. However, you can give us other bills for different months (ex. your June electric bill).
If you have a caregiver you would prefer us to contact about your financial assistance, or the applicant is a minor, please provide the caregiver/guardian's information below.
Please continue to next page.
Cancer Care Services is proud to provide non-financial services to anyone impacted by cancer. If you are interested in a service, please click it and you will get more information about it!
Cancer Care Services offers free-of-charge individual counseling for ages 5 and up. Counseling is available to Tarrant County residents only. Virtual counseling is offered!
Please give us the best phone number and email to contact you, your caregiver, or a parent/guardian (if not provided above).
Please write days and times that would be best for us to contact you to do a separate counseling application.
If you do not live in Tarrant County or do not want counseling from us but still want support, the following resources may be helpful for you:
Our CONNECT program brings you together with other people who have been impacted by cancer through fun events like movie nights, holiday events, and camps/retreats. The CONNECT program is open to anyone, regardless of treatment status, income, or where they live.
The email you gave at the beginning of this application will be used to send our monthly list of events. Please reach out to us at 817-921-0653 if you do not have an email or if you have questions about events!
If you would prefer the list of events to go to a different email, you can use the box below to tell us which email you want to use.
Thank you for your interest in Advanced Care Planning (ACP)! These conversations are important for everyone, because it gives you a voice if you are not able to speak for yourself.
There is no cost for notarizing the documents or consulting/helping you with your arrangements. Please write days/times you could be reached out to!
I can assist with:
Please note: I (NOTARY PUBLIC) AM NOT AN ATTORNEY LICENSED TO PRACTICE LAW IN TEXAS AND MAY NOT GIVE LEGAL ADVICE OR ACCEPT FEES FOR LEGAL ADVICE.
Due to liability concerns, I cannot notarize or assist with Last Will and Testaments.
If you need assistance with a Last Will and Testament, you can consult with an attorney or visit FreeWill for help: https://www.freewill.com/
Many people feel confused about insurance terms, their bills, and how to navigate our healthcare system. Financial Navigators at Cancer Care Services can provide you with information you need to help you through this journey.
Thank you for your interest in our financial navigation program! Please give us the contact information for the person who wants to receive financial navigation and days/times they can be contacted.
This is a tool we use to help understand what parts of cancer are causing you the most distress/problems right now. We can provide you with resources based on your answers. After the Distress Tool, you will have a section where you can tell us more about the needs you have right now.
The questions start with "Today, how concerned are you about..." The scale is 0-4, 4 being highest.
Here is a quick link to all of our events coming up!: https://cancercareservices.org/events/ NOTE: Certain events may require you to RSVP. The staff at these events cannot help you get financial services or answer questions about your application status.
Looking for other kinds of help too? Our website has resources for other agencies/non-profits that you can look through today! Here is the link: https://cancercareservices.org/resources/
Want to stay in touch with us and learn about what is new? You can sign up for our newsletter here: https://cancercareservices.us18.list-manage.com/subscribe?u=8ed7d64ddd31b3535f5159e49&id=8871a869c1
Please save our phone number, 817-921-0653, into your phone/contact list so that our calls do not show up as spam. If you do not answer our contact attempts your application will be put on a waitlist.
Click Submit if you are ready to send us your application. Click Save if you need to come back to the application later.