Instructions for Applying for Assistance

We’ve created new instructions for applicants. Please download and follow these instructions to help expedite your application.

1) Application Form Page 1 and Application Form Page 2 All areas must be completed (except those marked RCCC Rep) Please give as much information as possible.

2) Authorization for Disclosure of Health Information

3) Diagnosis Verification Form

All three forms listed above must be returned to the RCCC board to have your request acted upon. Our mission is to assist cancer patients in the Rock County Area.

———————Please Note—————————

Due to ongoing problems with Charter and Spectrum. RCCC will no longer be able to pay those bills for our clients. There have been numerous times that they have not credited RCCC client accounts for the money, but the checks have been cashed That has led to quite a bit of trouble for the client and RCCC’s.

As applications are submitted, each will be given a case number, allowing as much confidentiality as possible, with only one board member knowing the applicant’s name.  We are dedicated to being fair to everyone and it is our hope to be able to meet the needs of everyone that apply.