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 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.
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.