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Financial Assistance Programs Pre-Qualification 

(New Mexico Residents)

INSTRUCTIONS

 

To qualify for the PINK “ME” ® financial assistance programs please see the eligibility requirements below. This application, along with supporting documentation, must be submitted.

 

SUBMISSION DOES NOT GUARENTEE FUNDING 

  • We cannot guarantee that you will be selected for the program for financial assistance grant, even if you meet the qualifications and apply

  • All information provided will be kept confidential

  • Applications received are determined on a case by case basis- if not all required items are submitted, we will ask you to submit the documents before being considered

  • Once all items are submitted, you will be notified via email within 30 days if you have received the financial assistance from financialassistance@pink-me.org

  • If you need assistance completing this application, please contact us at financialassistance@pink-me.org, so we can provide you with assistance

 

 

QUALIFICATIONS

 

  • Must be diagnosed with breast cancer and currently in active treatment for the Breast Cancer Treatment Assistance Program -OR-

  • Must be a breast cancer survivor post one year treatment for the Survivor Health and Wellness Assistance Program

  • Provide and submit all required documentation along with this application (please review Financial Assistance Documentation requirements on our website)

  • Breast Cancer Treatment Assistance Program awards up to $1,500.00 financial assistance

  • PINK "ME" provides up to $1,500 in financial assistance through direct bill payments over the course of 3 months (example $500/month x 3 months).

  • Survivor Health & Wellness Assistance Program awards up to $600.00 financial assistance

  • PINK "ME" provides up to $600 in financial assistance through direct bill payments over the course of 3 months (example $200/month x 3 months).

IMPORTANT INFORMATION

Our Financial Assistance Committee will review your online application and email you within 5 days, regarding your application status. If additional information is needed, we will contact you.

ALL APPROVED GRANTS ARE BASED ON FUNDING AND FINANCIAL RESOURCES AVAILABLE

Please direct all of your questions to:

financialassistance@pink-me.org

PINK "ME" FINANCIAL ASSISTANCE

PROGRAM GRANTS ARE PROVIDED ON

A ONE-TIME BASIS ONLY

Financial Assistance Pre-Qualification Application 

Choose one grant quarter (select only one option- grants are paid over the course of 3 months):
Please indicate which program you are applying for:
Are you in active treatment?

Active treatment is defined as the period after a positive diagnosis of breast cancer has been made (with a diagnostic biopsy), and during which therapies are being administered, including surgical procedures to remove the cancer (e.g., single, or bi-lateral mastectomy, lumpectomy, axillary dissection, or sentinel node biopsy), chemotherapy or radiation. Active treatment does not include reconstruction surgeries or long-term hormonal therapies.

Select one
Proof of Income/ Employement Status of Applicant

All applicants must provide one (1) of the following proofs of income. If documentation cannot be provided, you may submit a written signed statement describing your income. Please circle what item of income you are including with this application.

 

  • W-2 statement

  • Three (3) most recent pay stubs

  • Last year’s income tax return

  • Written signed statement

YOUR STORY – Please share your breast cancer journey. This will not be shared unless approved in section E, but we will use your story to help make a decision of the financial assistance. Attach additional pages if needed.

AUTHORIZATION

 

If approved for the financial assistance, PINK “ME” asks for your permission to share your story with others to help raise public awareness of the organization, communicate to donors and community to support the cause, and inform breast cancer patients, healthcare providers, and others about the Organization’s services.

 

IMPORTANT: You do not have to authorize permissions, this will in no way affect your financial assistance status for the program.

 

I understand I have the right to revoke my authorization at any time by contacting PINK “ME” at info@pink-me.org or at the below address. Revocation will be effective upon receipt and affects disclosure moving forward and it is not retroactive. I understand that my approval or denial of permission will in no way affect the assistance provided to me by the Organization.

 

 

 

Yes I allow PINK"ME" to use:

I understand that information disclosed may be subject to redisclosure and may no longer be protected by Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act.

I understand that PINK “ME” Organization owns all marketing and outreach materials as released by me, and I hereby release rights to these items. I understand I will not be compensated for the use of the released information. I have read and understand the terms of this release. I certify that I am of legal age, 18 years of age or older.

I understand that PINK “ME” ® may verify information by reviewing information and obtaining information from other sources to assist in determining eligibility for financial assistance or payment plans.

I affirm that the above information is true and correct to the best of my knowledge. I understand if the financial information I give is determined to be false, this may result in denial of financial assistance, and I may be responsible for and expected to pay for services provided.

 

IMPORTANT INFORMATION

Applicants selected in the financial assistance program(s) will be contacted via email from our financialassistance@pink-me.org email address. 

SUBMISSION DOES NOT GUARENTEE FUNDING

Upload Treatment Verification Letter
Upload Bill Statement
Upload Bill Statement
Upload Bill Statement

Thank you for submitting your application for financial assistance. Our committee will review and get back to you within 5 days. Please note that all approved grants are subject to funding and financial resources available. If we need more information, we will contact you. For any questions, please email us at financialassistance@pink-me.org.

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