Our main mission is to help patients in need. If you would like to be considered for funding please fill out the form below. We also ask you to download and print out the Authorization for Disclosure form and submit it with a letter from your family doctor or oncologist, stating you are currently receiving treatment for breast cancer. All three forms, along with a copy of the statement requesting assistance, are required before we can proceed with any form of payment.

You can mail the forms to:
Help The Fight
143 Oakridge Drive
Mountville, PA, 17554

Funding Form Request

Date

MM

DD

YYYY

Purpose of Request

Rationale

Approximate Cost

$

Patient's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

County of Residence

Phone Number

(###)

###

####

Household Income

$

Number of People In Household

e Signature

e Signature is required to finalize application

First Name

Last Name

How did you hear about us? (optional)

Email Address (optional)

Message (optional)

Please click on the Authorization For Disclosure form below to download and print: