• Patient Transportation Assistance Application

    Patient Transportation Assistance Application

  • The Mission Cancer Foundation is pleased to assist cancer patients experiencing transportation-related barriers to and from cancer treatment appointments. To be considered for support, please complete the application. Assistance is determined based on treatment schedule, travel distance, and available funding, and is provided in the form of $25 or $50 gas cards.

    Gift cards are available based on financial resources and may not be guaranteed. If you have any questions on this form, please contact the Foundation at foundation@missioncancer.com or 515-235-8368.
  • Mission Cancer Foundation’s Transportation Assistance Program is for cancer patients who illustrate financial need and have no alternative transportation to their treatment center within the 26 Iowa counties served. Do you meet this qualification?*

  • HIPAA Disclosure

  • 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.

  • Patient Information

  •  - -
  • Gender*
  • Ethnicity*
  • Preferred Language:*

  • Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you a caregiver/guardian filling out this form on behalf of the patient?*

  • Healthcare Information

  • What kind of cancer are you being treated for?*
  • Primary Insurance Carrier*
  • What type of support would you like?*
  • Would you be interested in learning more about the American Cancer Society's Road to Recovery program where volunteer drivers are able to drive patients to and from treatment?*
  • Would you be willing to share about the impact of this grant to help and/or inspire others?*

  • Thank you to the American Cancer Society for providing a Patient Transportation Grant to the Mission Cancer Foundation to help support people facing cancer!

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