Application

Patient Treatment Assistance Guidelines,
Requirements, & Application

Submit application as soon as possible after breast cancer diagnosis.

Types of expenses covered

Surgery (excluding reconstruction), Chemotherapy Administration (excluding medications), Radiation Therapy, Insurance Co-Payments, Insurance Deductibles, and COBRA (for patient only)

Applicant Requirements

  • North Carolina resident who has been diagnosed with breast cancer
  • Must be a US citizen
  • Must be in active treatment
  • Financial assistance is only provided after application approval
  • Assistance is determined using the current Department of Health and Human Services Poverty Guidelines
  • Family Size of 1    Max    $30,150
  • Family Size of 2    Max   $40,600
  • Family Size of 3    Max   $51,050
  • Family Size of 4    Max   $61,500
  • Family Size of 5    Max   $71,950
  • Family Size of 6    Max   $82,400
  • Family Size of 7    Max   $92,850
  • Family Size of 8    Max   $103,300

Instructions

  • Complete Preliminary Financial Request Form to determine if you qualify for application
  • If approved, additional information may be requested
  • Medical Referral Form must be completed by your referring physician providing treatment (Oncologist, Surgeon or Radiologist)

Must submit with Application

  • Last 2 pay stubs or proof of unemployment
  • Current federal tax return or Schedule C if self-employed
  • Copy of utility bill
  • Copy of driver’s license or state issued ID
  • 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 will be processed when all required documents are received
  • Approval may take up to 30 days
  • Our Medical Advisory Committee sets the eligibility criteria and has final determination in all cases
  • Preliminary Application Form (click link to download)

Fax or mail completed application and supporting documents to:

Pretty In Pink Foundation                                    Questions?

6500 Creedmoor Road – Suite 106                    Call : 919-532-0532

Raleigh, NC 27613                                                 Fax:  919-977-6759