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 * Single Married/Domestic Partner Divorced Separated

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 * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

County *

Zip Code *

Place of employment *

2. Income Verification: Please provide 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.