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

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: $

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