The Head and Neck Cancer Alliance is proud to offer our Gas Card Program, which supplies a limited supply of BP and Exxon gas cards in the amount of $50.00 to head and neck cancer patients to help with transportation to and from treatments. This patient assistance is made possible by three private donors to whom we are greatly indebted.
To apply for assistance through our Gas Card Program:
Download the form below, and fill it out with the assistance of your healthcare provider’s office, patient navigator, social worker, etc. (Navigators and administrators: Please discard other versions of the application, and use ONLY the form available at the link below.)
Submit all gas card applications or questions to firstname.lastname@example.org. We no longer accept faxes. We cannot guarantee receipt of applications submitted by fax or sent to other email addresses.