BC Travel Treatment Fund - Online Application Form

Form A: Traveling Less than 25 Km

Consent Requirements

This application form is to be completed by patients, caregivers, or hospital/cancer clinic staff only. Patient information can only be submitted if the patient or their authorized representative has given consent to share their information with the Canadian Cancer Society (CCS).

Overview

We know that getting to cancer treatment can be difficult, especially if you are also dealing with physical or financial challenges, or if the treatment centre is far from home. Our Travel Treatment Fund is a financial grant available to help offset costs of travelling to cancer treatments.

If you are approved for the Travel Treatment Fund, you are eligible for a one-time payment per year while undergoing active treatment. This payment is made directly to you by a cheque mailed to the address provided on this form.

Getting Started
Before proceeding with the online form, ensure the following:

1.) BC Cancer Number: Obtain this information from your healthcare professional.

2.) Eligibility Criteria: this form is for patients travelling less than 25km for their cancer-related appointment.

Note: If your travel distance is less than 25km, you do not need a healthcare professional sign-off to complete this online form.

If your travel distance is more than 25km, click here to download and submit Form B.

If you have questions about the process or the information you need to submit, please call us at 1-888-939-3333.
We’re here to help.

Section 1 - Your eligibility

A cancer diagnosis

You are currently in active treatment, or you have completed your cancer treatments on or after April 1, 2023
There is no minimum number of treatment appointments required to qualify
Your household income and travel distance meet criteria listed in Section 3 of this form
People who receive the BC Employment and Assistance program may still apply for the Travel Treatment Fund
You have not received Travel Treatment Funding in the previous 12 months

Section 2-Your contact information

First name

Last name

Main phone number

Permission to leave voicemail on main number?

YesNo

Alternate phone number

Permission to leave voicemail on alternate phone number?

YesNo

Residential Address

City

Province

Postal code

Mailing Address (if different) Please include PO Box/Apartment/Suite/Unit etc.

Please use alpha-numeric characters only [a-z, 0-9].

Email address

Section 3 -Your household income

Please select the option that matches your current household financial situation:

Are your travel costs being covered in full by any other organization?

YesNo

Patient / Caregiver Initials

Section 4 - Estimated distance travelled (one way) to your treatment

What is the total distance from your home to the treatment centre? If you have travelled/expect to travel to multiple locations, please provide the distance to the location furthest from your home.

"Please input the distance traveled in Kilometer's (up to 25 km)" "If you travel distance is more than 25 km, please complete "Form B: Traveling more than 25Km"

Has Hope Air arrange travel support (flights)for you after October 2, 2023?

YesNo

Section 5 - Your Health Information

BC Cancer Identifying Number

Must be 7 characters long

Hospital/Cancer Centre Providing Treatment

Did you / will you receive treatment on or after April 1, 2023?

YesNo

Section 6 – Bone Marrow Transplant (BMT)/Car-T Therapy

Did you/will you receive a Bone Marrow Transplant or CAR-T Therapy?

YesNo

If yes, please indicate the date of the Bone Marrow Transplant/CAR-T Therapy

Name of clinic where you received / will receive a Bone Marrow Transplant or CAR-T Therapy

Type of treatment you received/will receive:

Auto (Autologous Stem Cell Transplant)Allo (Allogeneic Stem Cell Transplant)CAR-T Therapy

Section 7 - Our privacy policy

We collect your personal information through this and other forms to register you as a client and to communicate with you about your application for the Travel Treatment Fund. Information collected may also be used for other applicable CCS transportation, accommodation, information programs and services. We may share your personal information with third parties, including Hope Air, within or outside the province of British Columbia or outside Canada to carry out the purposes identified above, or as required by law.

You have the right to withdraw your consent to the use or communication of your information at any time. We may contact you by mail, email, phone or text. You can exercise your right to access your information or have it rectified or unsubscribe from communications by calling 1 888-939-3333 emailing BCTravelFund@cancer.ca

For more information about our privacy practices, visit www.cancer.ca/privacy

Section 8 - Patient Consent and Signature
(to be completed by patient or patient's caregiver)

I HEREBY CERTIFY that the information provided above is complete, true, and correct.
I understand that the information provided in this application will be validated by Canadian Cancer Society staff and additional financial documentation may be requested if necessary.
I agree to send and receive communications including personal health information by email.
I agree that the Canadian Cancer Society will not be liable for any breaches of privacy, whether caused by me or a third party.

Patient or Caregiver Full Name

Date