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Application Form

You can download and fill out the Application Form or apply online below.

By filling out the application form, you are acknowledging you have read and understand the Grant Restrictions and HIPAA guidelines. The completed Health Statement and the Income Documentation listed below are required in addition to the grant application.

With this application, you will need to email or mail the following before your application will be considered complete:

  • Most recent Income Tax Return, or if a Tax Return has not been filed for either the current or last calendar year; then W-2s or
  • Two recent pay stubs showing current income; or
  • Social Security award confirmation letter; or
  • Copy of Medicaid Card, or other Medicaid verification

If your Income Status changes, you must immediately notify the We Care Endowment to determine whether or not you continue to qualify for assistance.

Additionally, you will need to email or mail the Health Statement document. Download and print the Health Statement for your medical team member to complete and sign verifying your current treatment plan. Your submitted application will be processed once the completed Health Statement and require Income documentation has been received.

Online Application

By filling out the online application, you are acknowledging you have read and understand the Grant Restrictions and HIPAA guidelines. The completed Health Statement and the Income Documentation listed below are required in addition to the grant application.

With this application, you will need to email or mail the following before your application will be considered complete:

  • Most recent Income Tax Return, or if a Tax Return has not been filed for either the current or last calendar year; then W-2s or
  • Two recent pay stubs showing current income; or
  • Social Security award confirmation letter; or
  • Copy of Medicaid Card, or other Medicaid verification

If your Income Status changes, you must immediately notify the We Care Endowment to determine whether or not you continue to qualify for assistance.

Additionally, you will need to email or mail the Health Statement document. Download and print the Health Statement for your medical team member to complete and sign verifying your current treatment plan. Your submitted application will be processed once the completed Health Statement and require Income documentation has been received.

Application

I have read and understand the Grant and HIPPA information listed above. *
Yes

I understand the completed Health Statement and Income Documentation need to be emailed or mailed to the We Care Endowment office to complete my application. *
Yes

I am a Nebraska Resident *
Yes

County of Residence *

New Applicant *
YesNo

Who is filling out this application? *
PatientPatient Representative

Patient Representative, if applicable

Patient Name *

Gender *
MaleFemale

Birth Date (MM/DD/YYYY) *

Marital Status *

Address *



Phone Number *

Email *

Patient Language *

Okay to contact Patient? *
YesNo

Alternate Contact Name

Relationship to Patient

Alternate Contact Phone Number

List Total Household Gross Monthly Amounts from All Sources

Monthly Salary *

Monthly Disability *

Monthly Alimony/Child Support *

Monthly Social Security *

Monthly Pension/Retirement *

Other Monthly Income *

Total Household Monthly Income *

Total Number Living in Household *

Prescriber Information

Facility/Practice Name *

Prescriber's Name *

Address



Phone Number

Fax Number

Insurance Information *
PrivateMilitaryMedicareMedicaidUninsured

Your Condition

Type of Cancer *

Length of Cancer Treatment *

I understand that the We Care Endowment will request only that information needed to process and administer this application. We will not disclose the information obtained except as needed for this purpose or as required by applicable law. I hereby represent, covenant and certify as follows that the information contained in this application is complete and accurate to the best of my knowledge. The foundation may revise, change or terminate the grant at any time.

I have read and understand the above statement. *
Yes

Signature (Your Name) *

Date (MM/DD/YYYY)*

By including your name and submitting this Application, you represent that all information in true and correct in all resepects and that you will provide any additional information We Care Endowment may at anytime request to verify its truth and accuracy. We Care Endowment 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.

Once a determination has been made, you will be notified.

Additional Comments