RFS - Douglas County Cancer Services

request for service (rfs) agreement

fill out the information below:

Patient First Name

Patient Last Name

Date of Birth

Address

City

State

Zip

Phone Number

Cell Number

How did you hear about us?

Medical Professional Name

Medical Professional Phone

Services Requested

Wig Hat Turban Scarf

Number of Items

Breast Prosthesis

Number of Items

Cancer Diagnosis

Treatment Started

Gas Card

Gas Card Amount

Food Card

Food Card Amount

Financial Aid

Rent/Mortgage Utilities Other

Specify Other

Rent/Mortgage Amount

Utility Amount

Other Amount

Copies of bills required

Number in Household

Ages in Household

Personal Income (Self)

Personal Income - Others in Household

Social Security

Social Security - Others in Household

VA Pension/Disability

VA/Pension - Others in Household

State Wages or Pension

State Wages or Pension - Others in Household

Federal Wages or Pension

Federal Wages or Pension - Others in Household

County Wages or Pension

County Wages or Pension - Others in Household

Other IE: WIC, SNAP, Church, UCAN

Other IE: WIC, SNAP, Church, UCAN - Others in Household

TOTAL MONTHLY INCOME - Self

TOTAL MONTHLY INCOME - Others in Household

How does your diagnosis and treatment(s) affect your monthly income?

Home Expense

Rent/Mortgage Expense

Food Expense

Medications / Medical Expenses for patient only:

Gas

Electricity

Water

Phone

Auto Payment

Auto Gas

Auto Maintenance

Life Insurance

Health Insurance

Auto Insurance

Other Insurance

Other Household Expenses

Total Household Living Expenses

Acceptance

By clicking this, you have agreed to accept our Terms & Conditions.

Your Full Name

Today's Date

All funds received by Douglas County Cancer Services remain in Douglas County to assist Douglas County cancer patients.

douglas county cancer services

request for service (rfs) agreement

fill out the information below: