Breast Cancer Journey Assistance Fund Application 2025

Breast Cancer Journey Assistance Fund Grant Request Form

The Aesthetic Foundation is pleased to announce available funding to breast cancer patients on their reconstructive journey. The funds may be used for any breast cancer care, such as medication, medical equipment, respite care, living costs, support for loved ones and caregivers, wigs, and transportation to appointments, among other things. Funding will range between $250 – $500 and be deposited automatically.

Selection Criteria: Patient must be referred by a board-certified plastic surgeon, other physician, Nurse Navigator, or Social Worker.
Board-certified plastic surgeons, other physicians, Nurse Navigators, or Social Workers will fill out and submit the application.

The amount of funds awarded will be based on the phase and severity of treatment.
Patients may be asked to provide The Aesthetic Foundation with their breast cancer journey story for possible future use in printed and electronic communication.
If approved, payee information will be requested, and funds per patient will only be provided once every 12 months based on the last payment date.
If payee information is not received within 6 months after the date of grant approval by the Breast Cancer Journey Assistance Fund Task Force, a new application will need to be submitted and approved for the funds to be distributed.

ONLY PHYSICIANS, NURSES, OR SOCIAL WORKERS MAY FILL OUT AND SUBMIT THIS FORM. IF A PATIENT SUBMITS THIS FORM, IT WILL BE DENIED.

* Please note that it will take up to 6 weeks to review and process.

Please instruct the patient NOT TO CALL OUR OFFICE DIRECTLY regarding the status of their submission. All correspondence should be routed through you. Kindly advise the patient that the review, processing, and payment period will take up to six weeks.

For the request to be reviewed by the Committee, please use the following checklist and complete the items below to ensure your application is complete.

1. Your full name with credentials (board-certified plastic surgeon, other physician, Nurse Navigator, or social worker referring patient for funding). * Example: Jane Smith, MD, FACS

2. Your Phone Number (board-certified plastic surgeon, other physician, Nurse Navigator, or Social Worker referring patient for funding).

Format: (000) 000-0000.

3. Your email address (board-certified plastic surgeon, other physician, Nurse Navigator or Social Worker referring patient for funding).

example@example.com

4. Your mailing Address (Board-certified plastic surgeon, other physician, Nurse Navigator, or Social Worker).

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

5. Full name with credentials of the Physician treating the patient if different from above Example: Jane Smith, MD, FACS

6. Physician City and State if different from above

7. PATIENT NAME

First NameLast Name

8. Patient's FULL mailing address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

9. Patient's County

10. Patient Email

example@example.com

11. Patient Date of Birth

Date

12. Check all that apply.

13. Check all that apply.

14. Date of Diagnosis: Example: June 2023

15. Phase of Breast Cancer Journey: Check only one box.

16. Current Treatment:

Other

17. Choose all completed treatments, if applicable: Check all that apply.

Other

18. Most urgent financial assistance need (Please select only the top 3)

19. Amount Requested: Check all that apply.

20. The patient consents to their story/testimony/photo being used by The Aesthetic Foundation for future fund raising efforts to help more patients (not required to receive funds) Check all that you agree to:

21. Please have the patient read and sign the following confidentiality statement and upload at the bottom of application: *

Patient Participation Agreement and Medical Release

Please complete the Direct Deposit Payment Form and upload at the bottom of the application:

Direct Deposit Payment Form

I understand that the grant application process, including review, approval, and disbursement, will take up to 6 weeks. All communication regarding this application must be handled by the doctor, nurse, or social worker—not the patient.

Please upload the signed patient confidentiality statement and the ACH deposit form:

22. I verify and confirm that as the board-certified plastic surgeon, other physician, Nurse Navigator, or Social Worker and I have completed this application on the patient's behalf. I AM NOT THE PATIENT.

22. Please verify by adding your full name below with date. Example: John Smith, MD FACS 10/18/26