Financial Assistance for Patients
Cover Letter and Application
Grant Application and Grant Request Verification Forms
Qualifications (effective January 1, 2013, through December 31, 2016)
- Grant applicants must have a cancer diagnosis and be currently receiving medical treatment for cancer.
- Grant applicants must be a Colorado resident or receiving treatment in Colorado.
- Grant applicants must be 18 or older.
- Annual household income cannot exceed 175 percent of the federal poverty guidelines outlined below.
Gross Monthly Income
Add $557 for each additional person.
- All applications must be accompanied by a completed Grant Request Verification Form.
- Applications will not be considered complete without a verification of a cancer diagnosis and current treatment from a healthcare professional (physician, nurse, social worker, or patient navigator).
- Application may be downloaded below or you may call or e-mail to have an application mailed or faxed to you.
- Only completed applications will be reviewed.
- Applications that are incomplete will be placed on hold. We will contact you to let you know what is needed to complete the application.
- Applications may be completed by patient with help from any healthcare representative.
- Applications will be reviewed on a monthly basis.
Mail completed applications and supporting documents to:
Rocky Mountain Cancer Assistance
P O Box 6625
Denver, CO 80206
- Applications may also be faxed to us at: 888-600-4452
Click the above link to open it or right click to download the file. The application is a PDF. If you do not have Adobe Acrobat Reader, please click on the icon below to download the free software.
Adobe Acrobat Reader download icon: http://www.adobe.com/products/acrobat/readstep2.html
Applications are reviewed by the RMCA staff. Incomplete applications will not be considered and will be placed on hold until complete.
If an applicant is approved for assistance, the applicant will be notified by phone or e-mail regarding the amount of the assistance.
Financial assistance checks are made payable to the vendor and sent to the applicant for mailing to the vendor.
RMCA's financial assistance typically pays for the most basic of needs: food, housing, utilities, transportation, and health insurance premiums or COBRA payments.. This support helps reduce the stress of maintaining daily routines during treatment and contributes to retaining dignity and quality of life.