I.C.C.C. Application Form

Application for Cancer Patient Funds
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You may apply for funds to help with added expenses while going through the cancer fight. Before sending the application, please read the directions for completing the packet.

​All three forms included in the packet must be returned to the ICCC board to have your request acted upon.

Submit completed packet (includes 3 forms) to:
ATTN: Application Committee
Iowa County Cancer Coalition
PO Box 36
Cobb WI 53526

1)Application Form

• All areas must be completed. 
• Please give as much information as possible.
• Please sign and date form.

2)Authorization for Disclosure of Health Information

• This form must be filled out by the applicant before seeing your doctor. Leave a completed copy at the doctor's office to have placed in your medical record and keep a copy with you to mail to ICCC with your completed application.
• Please let your doctor / nurse know a member from ICCC board will be calling to verify the cancer diagnosis.
• Make sure the form is signed at the bottom.

3)Diagnosis Verification Form

• This form must be completed by your doctor.

Our mission is to assist cancer patients living in Iowa County, Wisconsin. 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 who applies.