Applicant Requirements
- North Carolina resident who has been diagnosed with breast cancer and is in any phase of treatment
- Must be a US citizen
- Must be in active treatment
- Financial assistance is only provided from time of application receipt and approval
- Need is based on the current Department of Health and Human Services Poverty Guidelines at 250%.
- Uninsured request are given priority
Instructions
- Complete Financial Assistance Request Form
- Medical Referral Form must be completed by your referring physician providing treatment (Oncologist, Surgeon or Radiologist)
Types of expenses covered
- Surgical consultations, Surgery (excluding reconstruction), Chemotherapy (excluding medications), Radiation Therapy, Insurance co-payments, and COBRA
Must submit with Application
- Last 2 pay stubs or proof of unemployment
- Current federal tax return or Schedule C if self-employed.
- Copy of bank statements from previous 2 months
- Copy of utility bill
- Copy of driver's license and social security card
- If applicant is insured: Copy of current medical card (front and back)
- If uninsured: Copy of Medicaid and/or Social Security, Disability rejection letters
Please note
- Applications cannot be processed until all required documents are received
- Approval may take up to 30 days
- Foundation grants assistance on a first-come, first served basis to the extent funding is available
- The Medical Advisory Committee sets the eligibility criteria and has final determination in all cases and reserves the right to change its program in its entirety or with respect to any applicant at any time with or without notice
Mail complete application and supporting documents to:
Pretty In Pink Foundation
2501 Blue Ridge Road-Suite 250
Raleigh, NC 27607