Application

Application
Dear Applicant,

Thank you for your interest in Friends In Pink. We understand your feelings and fears because we have been touched by breast cancer, and most of us are survivors. Friends In Pink is a charity that financially assists under-insured and uninsured patients diagnosed with breast cancer. We will do our best to assist you.

Please read the following carefully. You will need to complete all the forms with the exception of the “Letter of Support”. The “Letter of Support” ONLY needs to be completed if you have no proof of residency. An example of proof of residency is a utility bill (water and sewer, telephone or electricity) showing your name and current address. If you do not have proof of residency, the “Letter of Support” must be completed and notarized. Once the “Letter of Support” is completed and notarized include it in your application package and return the entire package to: Friends In Pink, 299 SE Wallace Terrace, Port St. Lucie, FL 34983.

Please check the “Eligibility Requirements” to make sure you have completed and enclosed all the information in the application. If information is missing or unreadable it could delay our decision making process. PLEASE KEEP A COPY OF THE APPLICATION FOR YOUR RECORDS.

We are here to assist you in any way we can. If you need help completing the application or have any questions, please don't hesitate to contact us at (772) 785-8730.

Your application will be reviewed for assistance once it has been completed and received.

Privacy Authorization Disclosure

(Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 & 164)
1. Authorization

I authorize Friends In Pink to use and disclose my protected health information to all relevant parties, so they may discuss my treatment and financial needs.

2. Effective Period

All past, present, and future periods.

3. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment.

4. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

5. I give permission for my protected health information to be disclosed for purposes of communicating results, and findings to the family members and others listed below:
Name
Relationship
Name
Relationship
Applicant Name

First NameLast Name
I have received a copy of the Friends In Pink Privacy Authorization Disclosure today.
Applicant Signature

Clear
Date

MonthDayYear
Date

Eligibility Requirements
Friends In Pink may provide financial assistance for your breast cancer care. Priority will be given to applicants permanently residing in Martin, Saint Lucie or Indian River County, Florida. Please complete the enclosed application and provide us with the following documents:

• Completed Privacy Authorization Disclosure form (HIPAA).
• Copy of Florida Driver’s License or Florida Identification Card.
• Copy of Social Security Card.
• Copy of Alien Card, Citizenship Certification or Work Permit, if any.
• Copy of Birth Certificate.
• Copy of last paystub from employer, if any.
• Copy of unemployment compensation check stub, in any.
• Copy of ALL Vehicle Registrations.
• Copy of Health Insurance Policy, if insured.
• Letter of Support, if appropriate.
• Copy of recent Utility Bill (power, phone, cable or water).
• Copy of the most recent Income Tax Return.

If you should need assistance with providing the above or completing the application, PLEASE feel free to contact us at (772)785-8730 and we will be happy to help you though this process.

We are here to help.
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Financial Assistance Application
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Social Security Number
Marital Status
Name of Doctor

First NameLast Name
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor's Phone Number
Please enter a valid phone number.
No. of people in Household
No. of children under 18

Please provide the following information completely and accurately. Information is subject to verification.
Are you employed?

YesNo
Employer Name
Do you have in insurance?

YesNo
Insurance Name
Patient/Responsible Party Information:
Monthly Income
Gross Income(before taxes) $
Other Household Gross Income $
Investment Income $
Rental Property Income $
Unemployment Income $
Other Income $
Total Income
Monthly Expenses
Rent/Mortgage $
Property & Health Insurance Expense $
Utilities Expense $
Food Expense $
Auto Payments (Loan & Insurance) $
Medical & Prescription Expense $
Other Expenses $
Total Expenses
Assets
Value of Residence $
Bank Account Balances (ALL) $
Auto Value $
Boat Value $
Recreational Vehicle Value $
Other Assets $
Total Value of Assets
Liabilities
Equity Loan $
Balance of Mortgage $
Credit Card Debt $
Auto Loan Balance $
Other Loan Balances $
Real Estate Taxes $
Estimated Medical Bills $
Other Liabilities $
Total of Liabilities
I hereby apply for financial assistance from Friends In Pink. I certify the information provided above is an accurate and a true representation of my financial information. I also certify that I have no additional insurance coverage other than stated above. I understand that providing false information will result in denial of assistance from Friends In Pink. I understand that my credit report will be used to verify this information. My failure to follow through with the application process or take actions to reasonably complete “Patient Eligibility Requirements” may result in denial of this application.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Application

Privacy Authorization Disclosure

Eligibility Requirements

Financial Assistance Application

Patient/Responsible Party Information:

Monthly Income

Monthly Expenses

Assets

Liabilities