Breast Cancer Solutions provides temporary financial assistance to eligible patients who are experiencing financial hardship as a result of their treatment. You may be eligible for financial assistance if you are currently in treatment for breast cancer, have financial need, and live in Orange, San Bernardino or Riverside County (CA).
- Click to print out these forms: AUTHORIZATION FOR RELEASE OF INFORMATION and PHYSICIAN REPORT.
- Fill out the AUTHORIZATION and give both forms to your doctor. Ask your doctor to fill out the PHYSICIAN REPORT, then return BOTH forms to Breast Cancer Solutions via mail or fax (information is on the forms) or by scanning and emailing to firstname.lastname@example.org.
- Complete the Online Financial Assistance Application.
2. Request application by mail
To request an application by mail, please call 866-960-9222.
Para recibir una solicitud por correo, llame 866-960-9222.
3. Download and complete application by hand
Download the Application in English
Download the Aplicacion en Espanol/Application in Spanish
Download the ĐƠN XIN HỖ TRỢ TÀI CHÍNH/Application in Vietnamese
You are not eligible for financial assistance if you:
- Have completed your surgery, chemotherapy and/or radiation; and/or
- Have no evidence of disease (NED); and/or
- Are taking a long-term hormonal treatment only (e.g., Tamoxifen) for stage I, II, or III cancer; and/or
- Are receiving hospice/palliative care only; and/or
- Are in the process of undergoing reconstruction but not receiving any other treatment; and/or
- Stop treatment for any reason against your doctor’s advice; and/or
- Have over $1,000 in liquid assets (does NOT include 401Ks, IRAs, vehicles or personal items)