GRACE Application Forms

Application for Cancer Patient Funds

Printable Directions for Completing Packet

  1. Complete the Application Form —(All areas must be completed except those marked Grace Rep. Please give as much information as possible. Please sign and date on line marked “Recipient”.)
  2. Complete the Authorization for Disclosure of Health Information —This form must be filled out by the applicant before seeing your doctor. The doctor must see this form to verify your diagnosis.
  3. Complete the Diagnosis Verification Form —This form must be completed by your doctor.
    All three forms listed above must be returned to the G.R.A.C.E., Inc. board to have your request acted upon. The G.R.A.C.E. board meets the second Tuesday of every month.
  4. The G.R.A.C.E office is open every Tuesday from 11am-1pm and every Thursday from 11am-1pm.
    (Please call ahead, as times are subject to change.)


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Greater Richland Area Cancer Elimination, Inc.

P.O. Box 213

Richland Center, WI 53581


“When the bad news is Cancer…The good news is G.R.A.C.E.”