Get Help: Application Process

PLEASE READ BEFORE DOWNLOADING 2 FORMS
Section 1: How does The Pink Fund help?
The specific objective and purpose of this corporation shall be to distribute short-term financial aid (defined as stated below; please read), in the form of direct bill payment of expenses for breast cancer patients (male and female) during active treatment or recovery (defined as stated below; please read), for breast cancer. This support can come in many forms: a car payment, house or rent payment, payments for medical or car insurance and utility payments are the most common. The Pink Fund does not make payments for any medical treatments, prescription drugs (including hormone therapy), medical co-pays, insurance deductibles, prostheses, wigs, etc.

Short term financial aid is defined as a period of no more than three months The Pink Fund will pay certain expenses of the recipient; paid directly on the recipient’s account. If recipient needs financial aid for greater than three months they can request an extension, (note:  this is subject upon approval by the Pink Fund Board). Maximum time aid can be received by any one individual is a six month period.

Active treatment is defined as: the period after positive diagnosis of breast cancer has been made, and a surgical procedure has taken place. Surgical procedure is defined as a single or bi-lateral mastectomy, lumpectomy, axillary’s dissection or sentinel node biopsy. Secondly, you are currently undergoing chemotherapy, radiation or biological therapy. Please note that complications from surgery, (i.e., blood clots, staph infections like cellulites, lymphadema, etc.), are not considered as part of being in active treatment for breast cancer.  In addition, subsequent surgery for related items like ovary removal, or reconstruction of the breast(s), and any associated related complications also does not qualify you for assistance from The Pink Fund.

Recovery is defined as:  A set period of time to be determined by your physician, but not to exceed more than 90 days after finishing treatment or surgery.

Section 2: Who does not qualify for aid from The Pink Fund?

• Applicant is currently receiving monthly financial aid through: a) the State and/or Social Security Disability programs, b) food stamps, c) financial aid, etc. through a local Department of Human Services of Welfare Unit, or, d) through the TANF (temporary assistance for needy families) Act
• Applicant is retired and receiving a monthly pension check from their former employer
• Applicant can not be on Medicaid unless it is through the BCCCP program, (Breast and Cervical Cancer Control Program)
• Applicant’s utility bills are currently being paid through a local Low income Home Energy Assistance Program, such as (NEAR) National Energy Assistance Referral, (866) 674-6327
• Applicant (or if dual income household), spouse/partner has been unemployed for more than 24 months
• Applicant is working in an unrecognized revenue producing position which is defined as: a) currently not paying federal or state taxes, and, b) receives cash under the table which is not reported to the government, (babysitting, grass cutting, dog watching, etc.)

Please Follow Steps 1 – 6 to complete The Pink Fund Application Process:

1. Submit a signed letter from your oncologist on letterhead verifying your current diagnosis and treatment plan, (refer to Section 1 for clear definition of what “in active treatment” means), or include a reference from a licensed social worker, case worker, patient advocate or nurse navigator. You must supply The Pink Fund with an email address for the social worker, case worker, patient advocate or nurse navigator (The Pink Fund will communicate with social workers, nurse navigators or patient advocates primarily through email. The Pink Fund will notify them when the patient is approved or denied for financial assistance.)
2. Provide a letter from your current employer indicating your employment status; you must be actively employed, or have recently lost your job, (defined as within the last three months).
3. Residency: Currently, you must be living in the State of Michigan to qualify.  Please provide a copy of your current driver’s license with an address that matches your application.  If you do not have a Michigan-issued license, you can submit a rental contract or mortgage bill with your name on it.
4. Print, Fill out and submit the “Personal Information” Form.
5. Print, Fill out and submit the “Medical Information” Form.
6. Ask your health provider for a HIPAA release form; fill it out and submit with your application.

Please mail your application and/or any additional confidential financial information you may be sharing with us by next day air through the US Post Office, United Parcel Service or Federal Express. This will protect both you and The Pink Fund. The address is:
The Pink Fund
22122 Metamora
Beverly Hills, MI 48025

Next Steps:
Once Steps 1-6 have been completed and the application received by our office, a member of the Qualified Recipient Committee will make the necessary follow-up phone calls to confirm treatment and employment status. 

Then, a brief phone interview with the potential recipient and a member of the Qualified Recipient Committee will be conducted, after which a file is provided to the Committee for consideration. The potential recipient will receive confirmation of acceptance or denial within 30 days of application.

All awards are made at the sole discretion of The Pink Fund. Each application is given careful, individual consideration but The Pink Fund does not guarantee assistance to anyone. Please notice that if you provide incorrect or misleading information on your application, on additional materials, or in any verbal communication with our Pink Fund personnel, The Pink Fund reserves the right to suspend immediately any and all current and future funding, and recover all such amounts already paid.

The Pink Fund in most cases will not be able to meet all your financial needs while you are undergoing breast cancer treatment. We strongly encourage you to explore all other options for assistance during this time.

>>>>> DOWNLOAD #1: APPLICATION <<<<<

Please include a copy of your most recent year's tax return and your most recent bank statements, both checking and savings for any and all banks where you may have funds on deposit.

>>>> DOWNLOAD #2: FINANCIAL DISCLOSURE FORM <<<<<

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