Gas & Grocery Cards

STEP

- PATIENT INFORMATION

Patient Information

Date of birth*

Address*

At this time, only those who reside in Oklahoma are eligible.

Patient gender*

Male

Female

Undisclosed

Other

NAME OF ONCOLOGIST/PHYSICIAN TREATING CANCER*

NAME OF HOSPITAL/CLINIC*

HOSPITAL/CLINIC ADDRESS

At this time, only those who reside in Oklahoma are eligible.

DISTANCE TRAVELED ONE-WAY TO TREATMENT FACILITY*

PHONE*

PRIMARY CANCER*

TYPE OF ACTIVE TREATMENT*

Chemotherapy

Radiation

Chemotherapy and Radiation

Other

HEALTHCARE Information*

RELATIONSHIP TO PATIENT*

Physician

Nurse

Social Worker

Other

HAVE YOU PREVIOUSLY RECEIVED A GAS OR GROCERY CARD FROM TENACIOUSLY TEAL?*

Yes

DESCRIBE IN DETAIL WHY ASSISTANCE IS NEEDED*

I AM MOST IN NEED OF A*

Gas Card

Grocery Card

ETHNICITY AND RACE*

CURRENT EMPLOYMENT STATUS*

EST. GROSS HOUSEHOLD INCOME:*

Patient VERIFICATION

Max. file size: 50 MB.

Please provide patient verification in the form of a letterhead from your treatment facility. This verification needs to include the beginning and end dates of your treatment, as well as details about the type of treatment you are currently receiving.

AS THE PATIENT OR HOSPITAL REPRESENTATIVE, I UNDERSTAND THAT BY SIGNING THIS APPLICATION I AGREE WITH THE FOLLOWING (PLEASE CHECK EACH BOX ACKNOWLEDGING THE STATEMENT):*

VERIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUTHFUL AND ACCURATE TO THE BEST OF MY KNOWLEDGE

AUTHORIZE TENACIOUSLY TEAL TO VERIFY ANY HEALTHCARE INFORMATION PROVIDED WITH THE VERIFICATION CONTACT

PERMIT TENACIOUSLY TEAL TO CONTACT ME

PERMIT TENACIOUSLY TEAL TO CONTACT THE RETAILER TO VERIFY HOW THE GIFT CARD WAS SPENT

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Gas & grocery cards

Gas & grocery cards

Gas & grocery card application

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