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. Applicants must be over 40 years old and have a primary care provider. If you have application questions contact (616) 355-3865.

1. Patient Information

Marital Status

Patient First Name

Patient Middle Initial

Patient Last Name

U.S. Citizen

Yes

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

ZIP

Place of employment

2. Income Verification: Please provide gross monthly income

Income Verification

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

Total Combined Gross Monthly Income

Do you have health insurance?

Yes

If yes, insurance carrier:

Have you applied for Medicaid?

Yes

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 Breast Care will contact you to discuss your application.