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Comprehensive Cancer Control Program (CCCP) Request for Travel Assistance for Appointments - PY5

Welcome!

The CCCP helps to pay for the cost of lung and colorectal cancer screenings for SPIPA eligible Tribal members. People who are eligible can receive assistance with travel to screening and/or diagnostic appointments when they report a barrier or hardship related to travel.

The information being asked below will be used to determine your eligibility for travel assistance for your appointment. Please note: You must be enrolled with one of the 5 SPIPA consortium Tribal Clinics to receive additional assistance.
1.By completing this form, I agree to be contacted by the SPIPA Cancer Programs staff, who may ask for additional information in order to provide travel assistance.(Required.)
2.Contact information(Required.)
3.It is hard for me to afford or plan travel to my cancer screening/treatment appointments.(Required.)
4.What is your gender?
5.Please select the clinic where you receive care.(Required.)
6.Please select the type of cancer screening you will be receiving? (Select all that apply)(Required.)
7.Please provide the date of your appointment or the date you were referred if your appointment has not been scheduled yet.(Required.)
Referral
Appointment
The CCCP can provide up to 4 cards per person per program year. **A new Travel Assistance Survey must be filled out for each appointment. **