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).
READ BEFORE APPLYING:
- Submitting a completed application does NOT guarantee that you will receive financial assistance.
- Please call 1-866-960-9222 if you have questions regarding financial assistance.
- Click the link above to request an application by email or postal mail.
- When you receive your application, fill out pages 1-4.
- Fill out the top of page 5 (AUTHORIZATION), then give pages 5-6 to your physician to complete.
- Submit your entire application to Breast Cancer Solutions by mail, fax, or scan/email to firstname.lastname@example.org.
- Your application will not be processed until we have received all 6 pages.
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.
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)