Contact the Pinkout For Hope Patient Assistance Coordinator, Amy Douglas, for more information, at (629) 867-6305.
You may qualify for assistance if:
- You are actively receiving treatment for breast cancer.
- 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.
- 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:
- 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.
- 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.
- Letter of cancer diagnosis from your Doctor– Mail to Pink Out For Hope, PO Box 263, Pleasant View, TN 37146
- 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.