GRACE Application

Application for Cancer Patient Funds

Application Form
Diagnosis Verification Form
Authorization for Disclosure of Health Information
Printable Directions for Completing Packet

Directions for Completing the Packet

  1. Complete the Application Form -- (All areas must be completed except those marked Grace Rep. Please give as much information as possible. Please sign and date on line marked "Recipient".)
     
  2. Complete the Authorization for Disclosure of Health Information -- This form must be filled out by the applicant before seeing your doctor. The doctor must see this form to verify your diagnosis.
     
  3. Complete the Diagnosis Verification Form -- This form must be completed by your doctor.
     
  4. All three forms listed above must be returned to the G.R.A.C.E., Inc. board to have your request acted upon. The G.R.A.C.E. board meets the second Tuesday of every month.
     
  5. The G.R.A.C.E office is open every Wednesday from 10:00 a.m. - 2:00 p.m.
    (Please call ahead, as times are subject to change.)

Our mission is to assist cancer patients in the Greater Richland Area. As applications are submitted, each will be given a case number, allowing as much confidentiality as possible, with only one board member knowing the identity of the applicant. We are dedicated to being fair to everyone and it is our hope to be able to meet the needs of all that apply.

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