GREATER HOUSTON AREA

Medical Financial Assistance Application 2017-10-18T13:38:29+00:00

MEDICAL FINANCIAL ASSISTANCE

Hurricane Harvey: Emergency Assistance Online Submission Form
The Breast Cancer Charities of America's Hurricane Harvey: Emergency Financial Assistance program is to provide funds towards medical bills and living expenses to those effected by Hurricane Harvey. Applicants must reside in The Greater Houston area and have been treated for breast cancer within the past year. Please see below for more guidelines to applying to the Emergency Assistance program.

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 government issued photo identification
2. Provide current (within 90 days) copy of medical bills, and/or mortgage statements, lease agreements, utility bills or other bills related to damage from the storm.
3. Provide a current letter (within 90 days) of treatment/diagnosis from a medical professional. This letter must be on professional letterhead and include the patient's name, the date, and signature from a medical professional.
4. Must be a U.S. Citizen or Legal Resident
5. The applicant may not have received $5,000 from any iGoPink financial programs in the past 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 treatment facility billing department. 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

City
State/Province
Zip/Postal

Healthcare Professional Information

City
State/Province
Zip/Postal

Additional Questions

City
State/Province
Zip/Postal

Share Your Story!

Tell iGoPink a little more about yourself and your current situation. Share how the Emergency Financial Assistance program will help you and your family.
Drop a file here or click to upload Choose File
Maximum upload size: 134.22MB

Required Documents

In order to be considered for funding the patient must submit all required documents. Documents must be legible, 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
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