Client Assistance Online Form

Please read information about our service programs and areas served before completing this form. Please specify a best time to call between 10 a.m. - 3 p.m.

 *MHCF is assisting Michigan Clients only at this time.



First Name: Last Name:
Address:City:
State:Zip:
Email:Telephone:() -
Best Time to Call:Cancer Type:
How did you find us:

Comments:

Social Worker/
Nurse Navigator Name:

Social Worker/
Nurse Navigator Hospital Affliation:


Financial Needs:

 Prescription Cost and Co-Pays
 Health Insurance Premiums
 Medical Equipment and Supplies
 Medical Expenses
 Lodging
Travel Expenses

Planning  a cancer benefit?                      Yes  No
Planned Benefit Date:
* If you are thinking about hosting a benefit we can help!
Where did you hear about our benefit assistance program?