Pretty in Pink Champions

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

  • Surgery
  • Chemo Administration
  • Radiation Therapy
  • Office Co-Pays
  • COBRA
  • Insurance Premiums

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, ad 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.  Patient bills prior to application are not eligible for assistance.
  • Assistance is determined using the current Department of Health and Human Services Poverty Guidelines
  • Family Size of 1    Min       $11,670     Max    $29,175
  • Family Size of 2    Min       $15,730     Max   $39,325
  • Family Size of 3    Min       $19,790     Max   $49,475
  • Family Size of 4    Min       $23,850     Max   $59,625
  • Family Size of 5    Min       $27,910     Max   $69,775
  • Family Size of 6    Min       $31,970     Max   $79,925
  • Family Size of 7    Min       $36,030     Max   $90,075
  • Family Size of 8    Min       $40,090     Max   $100,225

Instructions

  • Complete Preliminary Financial Request Form (download link below) 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 bank statements from previous 2 months
  • 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

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

 

Donate
Get Help