Apply for Help

PCCF helps pay certain expenses up to $750 per year for patients who:

If you think you meet those requirements, we have two options for applying! Please download the application or fill out the form below.


Name of Applicant:


City, State, Zip:

Phone Number:

Email Address:

Healthcare Professional:

Primary Diagnosis:

Primary Physician:

Names and ages of your: current spouse and all of your minor children currently listed as your dependents

How is your Health Care Paid For (i.e. Medicare, Medicaid, VA, Private Insurance, etc.):

Total Amount Requested (up to $750):

How was this amount determined?

Briefly identify the need(s)

Have other resources been explored to meet the identified needs? Yes No

If yes, please identify source(s)

Briefly describe the applicant's situation (number in household, ages of household members, employment, marital status, etc.)

How is the applicant's health care paid for? (Medicare, Medicaid, District Clinic, VA, Insurance, CIDC, Self Pay)

Identify sources of monthly income and expenses.

Total Monthly Income:

Total Monthly Expenses:

Verification of Income:

Copies of Current Bill:

1. All information is true and accurate to the best of my knowledge.

2. I give my permission that this form can be shared with the program committee and board of directors if neeeded.


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