Apply for a Patient Assistance Grant

SECTION 1 — APPLICANT INFORMATION

Full Legal Name: Date of Birth: Mailing Address: Phone Number: Email Address: Preferred Contact Method: ☐ Phone ☐ Email ☐ Mail

SECTION 2 — DIAGNOSIS INFORMATION

Date of original breast cancer diagnosis: Current stage/diagnosis (if known): Are you currently in active treatment? ☐ Yes ☐ No

SECTION 3 — FINANCIAL HARDSHIP

Current household size (including yourself): _____________ Have you experienced a reduction in income due to your diagnosis or treatment? ☐ Yes ☐ No What do you need help with? See Section 4

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SECTION 4 — ASSISTANCE NEEDED

Please describe the medical bills or treatment-related expenses you need help with: Total amount of outstanding medical bills: $______ Amount of assistance you are requesting: $______ What specific bills would this grant help you pay? (check all that apply) ☐ Hospital bills? ☐ Surgeon or physician fees ? ☐ Chemotherapy or infusion costs? ☐ Radiation treatment ☐ Prescription medications ☐ Medical equipment or other? ☐ Transportation to treatment ☐ Rent ☐ Other: _________________________________________________

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SECTION 5 — YOUR STORY (optional but encouraged)

In your own words, please share anything you’d like us to know about your situation. There are no wrong answers — we simply want to understand what you’re going through. (space for open response)

SECTION 6 — REQUIRED DOCUMENTS = NONE!!!