PLEASE READ THE INFORMATION BELOW PRIOR TO COMPLETING THE APPLICATION
Welcome to Pink Practicalities! This program is designed for people who are experiencing financial hardship while currently receiving breast cancer treatment (i.e. surgery, chemotherapy, radiation) and live or receive treatment in Clackamas, Multnomah, or Washington County in Oregon or in Clark County, Washington.
Distribution Per Fiscal Year (1/1/24-11/30/24): Yearly limits apply and are subject to fund availability. At this time, we will prioritize patients who have never received funding from us. Exceptions may be possible for those who have a diagnosis of A) metastatic breast cancer, B) a new primary breast cancer, or C) a recurrence of previously treated breast cancer who may be eligible for funds once a year. We do our best to provide financial aid to meet the greatest needs and help the most individuals.
Applications will be reviewed and responded to within 30 days. Completion of the form does not guarantee approval for funding.
Step 1: Patient Must Complete the Release of Information (ROI) Form
A completed Release of Information (ROI) Form is now required for enrollment in this program. This form should be completed by the patient or their authorized representative (e.g., Guardian, Executor of Estate, Health Care Power of Attorney).
Step 2: A Care Provider Must Complete This Form
The form below must be completed by a care provider, not the patient.