Forms for new and current clients
How to become a client
Follow these steps to become a client:
- Download each document below
- Complete your registration form
- Have your physician’s office fax or email the completed diagnosis form
Drop forms off at our office or in our Dropbox.
How to receive mammogram Services
How to qualify:
- Live in Ashland County
- Uninsured or Low income
- Denial from the UHSMC Financial Assistance Program
- Denial from Breast Cancer and Cervical Program
Contact us with any questions you may have
“I deeply appreciate all you do for me and other cancer patients as we fight this disease. I thank God for you.” ACCA Cancer Patient
As you start to address the emotional aspect of your disease you quickly realize the logistic and financial obstacles that are present on your road to recovery. It is truly a blessing to know we have a local agency to not only provide for your spirit but also face and overcome the obstacles along the way.