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 $31,225
- Family Size of 2 Max $42,275
- Family Size of 3 Max $53,325
- Family Size of 4 Max $64,375
- Family Size of 5 Max $75,425
- Family Size of 6 Max $86,475
- Family Size of 7 Max $97,525
- Family Size of 8 Max $108,575
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