request for service (rfs) agreement

Services Offered:
  • Transportation Assistance
  • Financial Assistance
  • Head Coverings (Wigs, Hats, Turbans, Scarves)
  • Bras and Prosthesis
  • Medical Equipment Referral


Services offered by Douglas County Cancer Services (DCCS) are determined by the following criteria:

  • The patient must be a resident of Douglas County.
  • The patient must currently be undergoing treatment for a cancer diagnosis.
  • Financial need of the patient.
  • The Request for Services must be completed in its entirety and signed by the patient and medical professional.
  • Financial disclosure must be completed and proof of income may be requested.
  • If able, the patient must present themselves to request and receive services.
  • Financial assistance will be determined on an individual basis and is based on available funding.


The following services may be provided to patients undergoing cancer treatment when the above criteria are met and a completed Request for Services is submitted:   

Transportation Assistance

  • A gas card may be provided if the patient travels more than 30 miles (round trip) for medical appointments and/or cancer treatments.
  • Other available resources have been researched i.e., Community Cancer Center van for radiation treatments.


Financial Assistance

Financial aid to assist with living expenses such as utilities, rent or groceries may be available and is dependent upon funding.

Head Coverings

Wigs, turbans, hats, and scarves are provided to cancer patients and survivors


Bras and prosthesis are provided to breast cancer patients and survivors.

Medical Equipment

  • Medical equipment such as a cane, wheelchair, walker, etc. may be available for loan to patients undergoing cancer treatment.
  • If approved and/or requested item is available, a referral will be given to the patient to obtain requested medical equipment from medical equipment supplier


  • All services are dependent upon available funding.
  • A listing of resources may be provided for your research for further assistance.  
  • A new Request for Services must be completed each time services are requested.
  • All lines on the Request for Services (RFS) form must be completed.  If the form is incomplete, delays in processing and approval may occur.
  •  Monthly income and expense information must be completed in its entirety on a yearly basis.
  • A copy of the bill must be provided if requesting funds for living expenses, utilities, phone, etc.
  • If approved, all payments made by DCCS for living expenses, utilities and phone will be paid directly to the bill provider.
  •  Requests for Services are reviewed by the officers of DCCS Board of Directors.
  •  Final determination is based upon completion of Request for Services, total household income and necessary expenses.
  • To ensure the most efficient process, patients are encouraged to down-load and complete the Request for Services (RFS) form online at
  • Douglas County Cancer Services is not meant to provide assistance on a regular basis and is a temporary funding source.


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