BarbaraCares - patient Application 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.
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.
The criteria are as follows:
In addition, the applicant must not have received assistance from The BarbaraCares Foundation in the past. Final approval for financial assistance is determined by the BarbaraCares Board of Directors.
APPLICATIONS MUST BE COMPLETED BY THE INDIVIDUAL NOT 3RD PARTIES OR SOCIAL WORKERS
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.
The criteria are as follows:
- Must be a legal Texas resident (Please include valid driver’s license)
- Only one award given per family/household
- Be a breast cancer patient undergoing active treatments (Must include documentation showing appointment to care for patient)
- Treatments are defined but not limited to: immunotherapy, radiation, surgery, chemotherapy, targeted therapy, or clinical trials. (Please send treatment schedule from physician).
- Be 18 years or older
- Currently experiencing financial hardship (Expenses must be greater than household income to quality. Please send a copy of recent paycheck stub, SSI benefits or unemployment received)
- Must include documentation supporting the diagnosis.
- Must send a copy of your most recent bills within 30 days for consideration. Please Note: Financial Grants are subject to availability of funding and can range between $250-500.00
- Extreme cases might be eligible for funding up to $2,000 - certain criteria must be met
In addition, the applicant must not have received assistance from The BarbaraCares Foundation in the past. Final approval for financial assistance is determined by the BarbaraCares Board of Directors.
APPLICATIONS MUST BE COMPLETED BY THE INDIVIDUAL NOT 3RD PARTIES OR SOCIAL WORKERS
