APPLICATION FOR ASSISTANCE

Please mail your completed form to:
P.O. Box 1924 Lakeport, CA 95453

Sponsoring Survivorship was established to help Lake County women cover costs associated with their struggle against breast cancer. This application will help us to understand in what areas we can assist you. Please remember requests should be made for medical assistance only. Co-payments and payments to doctors, hospitals and pharmacies as they relate to your care, purchase of prosthesis or other medical equipment as requested by your doctor or any other medical costs will be considered.

Name:________________________________________________________________________

Date of Birth __________________ Age:______________

Mailing Address:___________________________________________________________________________________

Street Address:____________________________________________________________________________________

City: ________________________________________ State:______________________________

Zip:_____________

Home Phone:____________________________ Work Phone: _____________________________________

Driver's License #: ____________________________________

Name of Physician: ______________________________

Date of Diagnosis: ____________________________________

Family History of Breast Cancer (Relationship):___________________________________________________________

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Amount of Assistance Requested $: ____________________________________________________________________

How funds will be used (please use reverse side of form for additional space if needed):_____________________________

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Marital Status:    Married    Single         Dependents (Names & Ages): ____________________________________

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Name of Insurance Carrier: __________________________________________________________________________

Pharmacy ________________________________________