BarbaraCares - AGENCY MAMMOGRAPHY SCREENING Assistance Form
Once we receive and review your application, you will receive a phone call to verify your information and eligibility. Approvals can take up to 2-3 weeks to process. The board members for the BarbaraCares Foundation meet on a monthly basis. Please be advised all applications will be reviewed at the next scheduled board meeting. Note: While we would like to respond favorably to all requests, understandably, the needs are far greater than our allocated resources and we are unable to accommodate them all. The Foundation only provides screening mammograms; specialty services and diagnostics are not provided through BarbaraCares.
Instructions:
Please read carefully to complete the entire form. You may electronically submit the application, or print the application and scan it for consideration via email at: [email protected] or mail the completed application form to:
BarbaraCares
P.O. BOX 15007
FORT WORTH, TX 76119
BarbaraCares has implemented the following criteria which must be met to establish eligibility for assistance. If you answer Yes or meet the guidelines to all of the questions below, you qualify to refer clients.
The criteria are as follows:
In addition, the applicant must not have received assistance from The BarbaraCares Foundation within the past 12 months. Final approval for financial assistance is determined by the BarbaraCares Board of Directors.
Instructions:
Please read carefully to complete the entire form. You may electronically submit the application, or print the application and scan it for consideration via email at: [email protected] or mail the completed application form to:
BarbaraCares
P.O. BOX 15007
FORT WORTH, TX 76119
BarbaraCares has implemented the following criteria which must be met to establish eligibility for assistance. If you answer Yes or meet the guidelines to all of the questions below, you qualify to refer clients.
The criteria are as follows:
- Agency must be headquartered in Texas
- Agency must provide a cover letter indicating an official request including: the amount, EIN number, name of referral, contact information on a company letterhead
- Referral recipient must be a legal Texas resident (Please include valid driver’s license)
- Only one award given per family/household within a 12-month period
- Must be referred by an agency, hospital or practice
- Be 18 years or older
- Currently experiencing financial hardship or currently unemployed or currently uninsured
In addition, the applicant must not have received assistance from The BarbaraCares Foundation within the past 12 months. Final approval for financial assistance is determined by the BarbaraCares Board of Directors.
