Help Now Fund Online Form

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2017 Help Now Fund Online Submission

The Help Now is a program for breast cancer patients, providing financial assistance for rent or mortgage and utility bills only. All qualifying applications will be submitted to the committee and considered for aid.

Consideration and/or Submission DOES NOT GUARANTEE funding. Due to limited funds, eligible applicants are NOT guaranteed approval.

To be considered the Applicant must:
1. Provide a copy of valid U.S. issued identification
2. Provide current (within 90 days) copies of bills and/or rental agreement
3. Provide a current letter of treatment/diagnosis from a medical professional
4. Must be a U.S. Citizen or Legal U.S. Resident. All Legal Residents must attach a copy of their residence card as well as valid governement issued ID.
5. The applicant may not have received $1000 from The Help Now Fund within the last calendar year
6. Applicants, please provide the Medical Release Agreement to YOUR medical professional listed on the application. Medical Release Agreements can be found here
7. Applicants, please provide the Billing Release Agreement to YOUR utility company, mortgage company, and/or leasing agency. Billing Release Agreements can be found here

Disclaimer:

DO NOT attach either the Medical or Billing Release to your application. These documents allow BCCA to retrieve basic information regarding treatment and billing, both are needed to complete the application selection process. Please provide these documents to the correct medical professional or company. If the applicant does not give the Medical or Billing Release documents to the appropriate party, the application may not be considered for funding. 

Patient Information

Patient Name (Nombre)
First Name
Last Name
Date of Birth (Fecha de Nacimiento)
Patient Street Address (Direccion)
Patient Email (Correo Electronico)
Patient Phone (Numero de telefono)

Healthcare Professional Information

* Healthcare Personnel Name (Nombre del Doctor o asistente social)
First Name
Last Name

Applicant Questionnaire

Street Address

Required Documents

In order to be considered for funding the patient must submit all required documents. Documents must be legiable, clear, and current.
Drop a file here or click to upload Choose File
Maximum upload size: 134.22MB
Drop a file here or click to upload Choose File
Maximum upload size: 134.22MB
Drop a file here or click to upload Choose File
Maximum upload size: 134.22MB
Drop a file here or click to upload Choose File
Maximum upload size: 134.22MB
Drop a file here or click to upload Choose File
Maximum upload size: 134.22MB
Drop a file here or click to upload Choose File
Maximum upload size: 134.22MB

Share your story

I authorize The Breast Cancer Charities of America (BCCA) to use my words as well as
photograph me (or use provided photos of me & my family) and acknowledge that all
photographs become the property of BCCA and will be used exclusively for the
programs and advocacy efforts of BCCA.

I agree that The Breast Cancer Charities of America may also omit or selectively add
words for editorial purposes to my story as it will not change the intent of my
testimonial.

I agree that The Breast Cancer Charities of America (BCCA) may use such
photographs of me with or without my name and for any lawful purpose, including for
example such purposes as publicity, illustration, advertising, and web content.

Drop a file here or click to upload Choose File
Maximum upload size: 134.22MB
Sending

Sorry, but this form is no longer accepting submissions.

Thank you for inquiring about the help now fund, applications are open and accepted the first through the fifth of every month only. If you are inquiring about the status of an application, someone will be in touch with you by the 15th of every month with an update. Decisions will not be made until the 15th of every month. For more questions please email helpnow@IGoPink.org