HFPF’s Financial Relief Program (FRP) provides direct financial assistance to qualified patients with co-payments, transportation expenses to treatment, prescription medications necessary and dedicated to specific disease states. In some instances, assistance with insurance premiums and/or ancillary services associated with the disease also may be available.

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Financial Relief patient assistance is purely donor-funded and money is dispersed to qualified patients while funds are available for each of the Diseases identified.

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Required Information to Complete an Application for Assistance:

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Patient Demographic Information

• First & Last Name

• Address & Phone Number

• Gender, Ethnicity & Marital Status

• Veteran Status, Employment Status, Date of Birth

• Social Security Number or Alien Number

• Financial Information

• Number in Household

Annual Household Income

• Do you file a Tax Return for the most current year?

• Has your Annual Income changed significantly from last year?

Medical Diagnosis

• Primary Diagnosis

• Date of Diagnosis

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Submitting Documents: What are the options?

 

For applications submitted through our website, supporting documents may be uploaded electronically

• Please allow 24 to 48 hours for uploaded documents to reflect on the online portal.

Applications and supporting documents may be emailed

• Please send documents to info@hopeforpinkfoundation.org.

 

I’m Approved, What Now?

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• Patients approved for assistance are required to have their verified diagnosis and treatment plan along with supporting documentation completed and returned within 30 days of approval to ensure continuation of the award.

• Approved patients who do not submit a completed physician form verifying the reported diagnosis within 30 days from approval will forfeit their award and will not be eligible to reapply to the program until 12 months from the original date of approval.

• If you are requested to provide documentation of your reported income, please submit your documentation to the program within 30 days of approval to ensure continuation of the award.

• If the requested income documents are not received within 30 days from the date the application was initiated, the award will be forfeited, and you will not be eligible to reapply to the program until 12 months from the original date of the application.

• Once approved, begin using your award immediately upon receipt! You will receive a check in the mail within 5-7 days after approval.

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