Breast Care Fund Financial Assistance Application

Early detection provides the best opportunity to treat breast cancer and reduce the risk of recurrence. The Breast Care Fund covers the cost of screening and diagnostic mammograms, ultrasounds and biopsies for women in our community who do not have insurance coverage for these life-saving tests.

Please complete and submit the below form for potential financial assistance. If you have application questions contact Alecia Jones, Breast Nurse Navigator ajones@hollandhospital.org or (616) 355-3871.

* indicates required field

1. Patient Information

Marital Status *

Patient First Name *

Patient Middle Initial *

Patient Last Name *

Email *

U.S. Citzen * YesNo

Date of Birth *

No. of Dependents (Under 18 yrs old)

Ages of Dependents

Primary Phone Number *

Street Address (Do not list PO Box) *

City *

State *

County *

Zip Code *

Place of employment *

2. Income Verification: Please provide gross monthly income

Monthly Income Sources	Patient	Spouse(if applicable)	Combined Monthly Income
Employment Income	$	$	$
Social Security	$	$	$
Disability	$	$	$
Unemployment	$	$	$
Spousal/Child Support	$	$	$
Rental Property	$	$	$
Investment Income	$	$	$
State Assistance (ie: food stamps)	$	$	$
Other	$	$	$
	Total Combined Gross Monthly Income: $

Do you have health insurance? * YesNo

If yes, insurance carrier:

Have you applied for Medicaid? * YesNo

I certify that all information is valid and complete and hereby authorize Holland Hospital to request a credit report and/or verify any of the above information as deemed necessary. *

After submitting the application a member of Comprehensive Breast Services will contact you to discuss your application.