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treatment assistance

An important part of our mission is to help relieve the financial burden that undergoing treatment for gynecological cancers can put on a patient and their family. If you or someone you know is currently undergoing any type of treatment (surgery, chemotherapy, or radiation) for a gynecological cancer and needs financial assistance please fill out the form below. 

Types of financial assistance that we cover:

Medical Bills, Transportation Services, Groceries, Gas

 

**Please Note - we are currently only accepting applications for NWI and Chicagoland residents. 

You will be contacted with a decision within 10 business days of application submission

Coverage for groceries and gas will be given in the form of a gift card.

Coverage for medical bills/transportation services will be paid directly to the servicer provider. 

If you prefer to print a form and email it back to us, you can download a form here. 

Apply Here

Personal Information 

Treatment Information 

Which type of gynecological cancer are you (the patient being) treated for? Please select all that apply.

Financial Details

Does the patient have medical insurance coverage? If yes, we will contact you via email to provide a copy of insurance.

Select an option
Type of financial assistance requested:

What does total gross annual income include?

Gross salary, unemployment payments, Disability and Worker’s Compensation, Social Security and/or Supplemental benefits, Public Assistance, Other income

Thanks for applying! We’ll get back to you soon.

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