Application for Assistance

We Are Here When

  • You do not have medical insurance
  • Your medical insurance does not cover all services for your breast cancer treatment

Financial Assistance for Those Who Qualify Includes for Assistance Toward Medical Expenses Associated With:

  • Surgery Consultations
  • Surgery (excluding reconstruction)
  • Chemotherapy Administration (excluding medications)
  • Radiation Therapy
  • Office Co-Pays
  • Co-Insurance
  • Insurance Premiums and Deductibles
  • COBRA Premiums

Patient Treatment Assistance Guidelines & Requirements

Submit your application as soon as possible after breast cancer diagnosis.

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
  • Household income guidelines for eligibility:
  • 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

Application Instructions

  • Complete and submit the Financial Assistance Request packet (download from link at bottom of page) by mail or by fax.
  • Have your physician (Surgeon, Oncologist or Radiologist) that is providing treatment complete the Medical Referral form and attach your medical Pathology Report.
  • Please note:  you can submit the Medical Referral Form and Pathology Report with your Financial Assistance Request Form;  Or you can have your physician’s office send it directly to us by mail or fax.

Additional Documents Required for Complete Application

After your Financial Assistance Request is screened and you meet initial eligibility, our Patient Resource Coordinator will contact you to make sure all additional documentation is submitted.  You may go ahead and submit these documents with your initial Financial Assistance Request.  These documents are needed to complete a full application.

  • Last 2 pay stubs or proof of unemployment
  • Most recent federal tax return (first 2 pages) or Schedule C if self-employee
  • Copy of utility bill
  • Copy of driver’s license or state issued ID
  • If you are insured:  Copy of current medical card (front and back)
  • If you are uninsured: Copy of Medicaid and/or Social Security Disability rejection letters, if applicable

Please Note

  • Approval by the Medical Advisory Committee may take up to 30 days
  • Requests can only be submitted to the committee for review after all required documents are received
  • Foundation grants assistance on a first-come, first-served basis to the extent that funding is available
  • Our Medical Advisory Committee sets the eligibility criteria and has final determination in all cases

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