Client Intake

  • Client Information

  • Spouse/Significant Other Information

  • Medical Provider Information of Client

  • Treatment Information: Current and Future

  • Enter name and phone
  • Check all that apply
  • Enter Commercial/Private Provider Information
  • Enter National or Local Organizations, if applicable
  • Cancer Assistance of Williams County (CAWC) is a nonprofit agency. Created to help cancer patients that live in Williams County.     The requirement for financial assistance is:
    • You must be a resident of Williams County, Ohio over 3 months.
    • Be within 1 year of diagnosis and seeking active medical approved treatment that is under the care of a licensed Medical Doctor. 
    • Authorize the use or disclosure of health information from the Physician, and treatment location listed. 
    Reasons for Financial Assistance Stoppage: 
    • Unnecessary duplication of services that would result in overpayment to client.
    • Dishonesty regarding reimbursement.
    • Clients that have entered into the Hospice period are no longer qualified for CAWC financial assistance.
    • Residents in nursing homes are not eligible for financial services.  
      In signing, I understand the information I supplied for intake is for the benefit of CAWC to provide services and to document outcomes.  I also understand and abide by the above CAWC Policy.    Authorized Signature___________________________________________ Date ____________
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