Notice:  Cinco Charities, Inc.® verifies all applications with the submitted referral source to determine eligibility. By submitting this application, you are authorizing Cinco Charities, Inc.® to verify with the referral source and the physician or hospital the information submitted herein. If you are uncomfortable providing this information online, you may download and print our application, and submit via fax at 281.220.6417 or by email at applications@cincocharities.org.