Thank you for contacting Patient Housing Assistance to request financial assistance for your lodging during your treatment.
To determine if you qualify for assistance, see the chart below:
You are a Patient/Caregiver:
You must be traveling for cancer treatment or medical evaluation for 7 or more consecutive days
Treatment must be at least 50 miles, one-way, from your home
You meet the income guidelines in the table to the left
Verification of treatment form must be filled out by a clinician
Total Maximum Gross Family Income
$48,560 or less
4 or more
If you believe you qualify based on the above eligibility requirements, please download and complete the application and submit the supporting documents by email to firstname.lastname@example.org. You MUST include financial documentation and verification of treatment by your doctor, nurse, or medical social worker. Your application will not be considered without the attachments; incomplete applications will not be considered for funding. Please note that a completed application is not a guarantee of receiving the assistance requested and may take up to 5 business days for notification of approval. Awards are based on current availability of funds.
If you have any questions, please feel free to contact us via phone281.507.2035 or email email@example.com.
Any information you share on the application is strictly confidential and for use by Patient Housing Assistance and its current Board Members only. Please do not submit original documents with your application as we will not be able to return them to you.