Grant Application – Hatteras Island Cancer Foundation

Hatteras Island Cancer Foundation will award grants to individuals diagnosed with cancer in order to help them defray the costs of treatment. An applicant must be a full time resident of Hatteras Island, and provide a copy of a photo ID with a Hatteras Island address along with this application. The foundation may assist you with the cost of travel, food, lodging and parking while seeking treatment off the island as well as medical and pharmacy bills not covered or not completely covered by insurance. If your grant application is approved, this does not guarantee full payment of all submitted bills.

If you request assistance with medical bills, you must provide a copy of the bills that have already been processed through your insurance company, if applicable. Please keep a copy for your records. In order to reimburse for mileage a travel form must be completed and initialed or stamped by the doctor’s office you are visiting.

Grant applications are reviewed the 3rd week of every month. Information provided in the application will be kept in the strictest of confidence.

The person signing this application warrants the information provided is true. Hatteras Island Cancer Foundation is authorized to make all inquiries deemed necessary to verify the accuracy of the statements herein.

Signature of Applicant*

Date*

File Upload - Upload a picture of a photo ID with a Hatteras Island address, and a copy of medical bills processed by your insurance company, if applicable*

Drop files here or

Max. file size: 8 GB.

APPLICANT INFORMATION

Name*

First Last

Age*

Email Address*

Physical Address*

Street Address City State ZIP Code

Mailing Address*

Street Address City State ZIP Code

Phone*

Alternative Phone

Are you a full time resident of Hatteras Island?*

Yes
No

Employer of Applicant*

Address of Employer*

Street Address City State ZIP Code

Other members of household (those living with applicants) - Click the green + to add another member*

Full Name	Relationship	Age

Type of Cancer*

Date of Diagnosis*

Primary Care Physician*

Do you have Medical Insurance?*

Yes
No

Name of Primary Insurance Company*

Name of Secondary Insurance Company

Do you have a supplemental cancer insurance?*

Yes
No

Name of Supplemental Insurance Company*

What type of assistance do you expect you will need? (Medical bills, pharmacy bills, travel expenses, etc.) Please list in order of importance according to your financial needs. Click the green + to add another need.*

Have you or anyone in this family applied for a grant from the Hatteras Island Cancer Foundation?*

Yes
No

Date of previous application*

Name of person in household*

HOUSEHOLD INCOME

Applicant Wages - monthly*

Spouse or Other Wages - monthly*

Child Support - monthly*

Unemployment - monthly*

Other - monthly*

TOTAL Household Income*

HOUSEHOLD EXPENSES

Rent / Mortgage*

Utilities - monthly*

Child Care - monthly*

Medical - monthly*

Insurance - monthly*

Other - monthly*

TOTAL Household Expenses*

Do you have additional funds that can be drawn from (such as checking, savings, stocks, bonds, retirement funds, etc)?*

Yes
No

Please list the value of the assets*

$10,000 - $25,000
$25,000 - $100,000
Over $100,000

Do you consent to allow HICF to contact your medical providers in attempts to negotiate and lower your bills?*

Yes
No

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APPLICANT INFORMATION

HOUSEHOLD INCOME

HOUSEHOLD EXPENSES

Hatteras Island Cancer Foundation

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