​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:
  • 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. 
    Max file size: 20MB
    ​Signature
    Please read the following information carefully before signing and submitting:  I hereby understand and recognize that the BarbaraCares Mammogram Screening Assistance Application is part of the BarbaraCares Foundation, a Texas nonprofit corporation which is a recognized tax exempt organization pursuant to Internal Revenue Code Section 501 (c)(3). Each award and grant has been solely and exclusively established for the benefit of those persons at risk of breast cancer or otherwise unable to afford mammography services.  Funds provided are not based on marital status, race, gender, ethnicity, orientation or religion. However, funds may be allocated to serve communities in greatest need.

    Accordingly, I have read and affirm all the information provided is truthful and accurate. I hereby certify  I am able to fill out documentation on behalf of the agency and that the financial information disclosed on this application concerning household income, expenses and insurance provider is true and accurate. 

    If funding is released for the referral, the agency will provide within 90 days of receipt of payment a final report to include patient demographic information, cancer status, mammography adherence, and final expense information. 

    I understand that if any of the information set forth above is false, the application will be denied and if funding has been released, the foundation will pursue any and all legal means available to retrieve disbursed funds.  

    By signing the signature/clicking the submit button below, I agree and give permission for the BarbaraCares Foundation to verify the provided information. 
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