Patient Grant Application
By filling out the online application, you are acknowledging you have read and understand the
Grant Restrictions, HIPAA guidelines, and Income Requirements.
Please review the Grant Eligibility and Restrictions here.
- Completed Application
- Income Documentation*
- Expense Verification
- Health Statement completed by Provider
*If you do not have income documentation, you may complete either the Statement of Support/Assistance Form or the Statement of No Income Form. See the Supporting Documentation page of the application for more details.
A member of your medical team must complete the Health Statement Form to verify your treatment plan. This form must be completed by your healthcare provider.
Your submitted application will be processed once the completed Health Statement, Income Documentation, and Expense Verification documents have been received.
If you are unable to complete the online application, please download the application and send a completed copy to NCS Hope Foundation via one of the following options:
- Email – firstname.lastname@example.org
- Fax – 402.691.1699
- Mail – 17201 Wright Street, Suite 200, Omaha, NE 68130