Patient Application

Apply for Assistance

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The Wichita Cancer Foundation works to provide insurance premium assistance to insured cancer patients. As a nonprofit organization, funding depends on the sources of support we receive at any given time. If you need help completing your application, please contact us about scheduling an appointment. If we do not currently have funding to assist you, please contact us for other financial assistance referrals.

  • Qualifications

    To qualify for Wichita Cancer Foundation insurance premium assistance, applicants must:

    • Be a US Citizen or permanent resident.*
    • Meet financial criteria based on household size and household income,* which is 500 percent of the poverty level according to federal poverty guidelines.
    • Have, or be in the process of securing, private health insurance, an employer-sponsored health plan, or COBRA insurance.
    • Be diagnosed with cancer.
    • Have cancer care initiated or received in the state of Kansas.
    • Not currently receiving government assistance through Medicare or Medicaid.

    *Supporting documentation may be requested at the discretion of the Wichita Cancer Foundation but is not required on the initial application.

Patient Application

Complete the initial form to see if you meet the qualifications for completing the full application: