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APPLICATION FOR ASSISTANCE

Pretty In Pink Foundation provides the financial assistance necessary to make survival a reality for breast cancer patients. If you are uninsured or under-insured and need financial assistance to help pay for lifesaving breast cancer surgery, chemotherapy administration, or radiation therapy, please contact us for more information on our program and eligibility. If you are ready to apply, you may download our Financial Assistance Request Packet or fill out the online application.  Submit your application as soon as possible after breast care diagnosis.

We Are Here When...

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

Financial Assistance

Includes assistance toward medical expenses associated with:

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

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 $39,125
  • Family Size of 2 Max $52,875
  • Family Size of 3 Max $66,625
  • Family Size of 4 Max $80,375
  • Family Size of 5 Max $94,125
  • Family Size of 6 Max $107,875
  • Family Size of 7 Max $121,625
  • Family Size of 8 Max $135,375

Application Instructions

  • Complete and submit the Financial Assistance Request packet 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.

Click here to download the Financial Assistance Request Packet

Additional Documents

Required for Complete Application

After your Financial Assistance Request is screened and you meet initial eligibility, you will be contacted 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 (If your income is solely Social Security or Social Security Disability Income, then a copy of Social Security or Social Security Disability Income statement or letter).
    • Most recent federal tax return (first 2 pages) or Schedule C if self-employee
    • Copy of utility bill
    • Your Story
    • Medical/Health Information Release & Authorization
    • Publicity Release
    • Copy of driver’s license or alternate 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

More Information

  • 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 & supporting documents to:

Address: 5171 Glenwood Avenue,  Suite 360, Raleigh, NC 27612

Fax: 919-977-6759

Questions? Call us at 919-532-0532

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