Pink Out for Hope - Breast Cancer Awareness

Need Assistance?


Contact the Pinkout For Hope Patient Assistance Coordinator, Amy Douglas, for more information, at (629) 867-6305.

You may qualify for assistance if:

  1. You are actively receiving treatment for breast cancer.
  2. You have a true financial need as determined by the Pink Out For Hope committee based on the availability of funds at the time of your request.
  3. You live in Cheatham County (TN) or the surrounding 37146 communities.

*Patient assistance requests are evaluated on a case by case basis and qualification for assistance is determined by the Pink Out For Hope committee.

**Providing your requested medical and financial information does not guarantee financial assistance.  Pink Out For Hope is not able to help with large expenses or long-term assistance.  

The following forms must be completed and submitted for approval before assistance can be given:

 

  1. Pink Out For Hope Patient Assistance Application – To be completed by patient or a representative of patient, signed and returned to Pink Out For Hope, PO Box 263, Pleasant View, TN  37146.
  2. Pink Out For Hope Permission Form (HIPAA Release Form) – To be completed by patient or a representative of patient, signed and returned to Pink Out For Hope, PO Box 263, Pleasant View, TN  37146.
  3. Letter of cancer diagnosis from your Doctor– Mail to Pink Out For Hope, PO Box 263, Pleasant View, TN  37146
  4. You must provide proof of residence in Cheatham County. This could be a utility bill, a copy of your driver’s license or voter’s registration.

All four of the above criteria must be received by Pink Out For Hope before your application can be considered.  Upon approval, a Pink Out For Hope representative will speak with you and/or your representative to discuss your financial needs.

 ***Pink Out For Hope does not discriminate based on any information received.