Thank you for your interest in the HNCA Gas Card Program. For years, we have supported head and neck cancer patients with a $50 gas gift card to assist with transportation expenses to and from cancer treatments. Thousands of patients have benefited from our Gas Card Program.
Due to high demand, all gas cards allotted for 2018 have been distributed to patients. Your request will be placed on a waiting list. Once additional support for the program allows us to replenish our supply of gas cards, we will reach out to you with an update on the expected delivery time.
Thank you for your understanding.
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 email@example.com. We no longer accept faxes. We cannot guarantee receipt of applications submitted by fax or sent to other email addresses.