 |
 |
|||||
 |
 |
 |
 |
 |
 |
|
* This application must be filled out by patient- NOT THE DOCTORS OFFICE.
PLEASE READ the entire page CAREFULLY before applying. Summary: - Assistance is made available to both men and women diagnosed with breast cancer through the Pink Ribbon Riders Assistance Program. - You must be in treatment for breast cancer to apply. - The Assistance Program is a volunteer driven program of caring people that oversee applications that are submitted to the Pink Ribbon Riders. The program is available due to the generosity of our donors and the volunteers that help with our fundraising events through out the year. - The Assistance Program is made available to provide direct financial support to breast cancer patients while they are battling the disease, our hopes are to make the days less stressful by helping with expenses faced during that time. Assistance Program Purpose and Mission: To provide financial support to breast cancer patients both men and women to make their fight against breast cancer less stressful. ____________________________________________________________________________________________ Policy: The policy is to guide the organization and its volunteers in processing requests from breast cancer applicants who have completed the application process to Pink Ribbon Riders in request for assistance. * We consider those patients from the states of: Michigan, New York, North Dakota, Wisconsin, Minnesota, Pennsylvania and Wyoming first.
* All other states will be determined if funds are available that period. * As a doctors office, please take this into consideration to be fair to your patients time when applying. * Pink Ribbon Riders is a very small volunteer grass roots effort organization and this should be taken in consideration for doctors offices and social workers when they refer patients to us. _____________________________________________________________________________________________ Policy Statements: 1. Applicant must be a U.S. citizen. 2. The application must be completed in full, including all required documents requested.
* Original signatures, No Faxes or copies of doctor signatures will be accepted.
4. The committee will have the right to make first determination of acceptance to applicants based on the states in which Pink Ribbon Riders hosts fundraising events in. **At the current time first determination will be made to applicants in the states of: New York, North Dakota, Pennsylvania, Michigan, Wisconsin, Wyoming, Minnesota 5. If funds permit during each period, applicants will be considered from outside of the current Pink Ribbon Riders host event states. 6. The Assistance Program has the right to have "open and closed" periods. If there is period where the program is closed. Notification will be done on this page of the website. * The website will be the official notice of the Patient Assistance Program. 7. Each applicant may apply for a maximum up to $500.00 a year (funds permitting). * The committee reserves the right to distribute assistance amounts based on funds available at the time.
Requirements to apply: 8. In order to establish financial need and to be considered, applicants must attach & send along with Part 2 of the application: : A) current income tax return - Page 1 showing proof of income. * if you are not working, you must show proof of the house hold income. * If you are only receiving social security - you must attach proof. * if you are only receiving unemployment or medical disability- you must attach proof. B) Medical bills showing treatment (copies only please)
C) Proof of citizenship - Forms accepted: 1) A copy of your drivers license 2) or Passport. D) A Doctor letterhead signed by treating doctor advising you are a breast cancer patient in treatment. * Must be an original and not a copy or fax copy. Important Facts: * Your application will NOT be processed or considered with out the above requirements.
* We can not accept other organizations applications. You must submit the Pink Ribbon Riders application. * We can not process applications in foreign languages. * Please do not call regarding your application. We will email you any questions.
The Application Process:You must be the patient to apply please. 1. Submit the completed application with all attached items needed. There are 3 Parts. -Part 1 is online - Part 2 & 3 are downloadable forms, you will be prompted after completing Part 1, and you will also receive and email with the link. - Mail part 2 & 3 and all attachments once you have completed the online form. - Please mail all parts and requirements together. -PRINT this GUIDE to help you. CLICK HERE. 2. Submit application to: Mail Part 2 & 3 and all required paperwork to: Pink
Ribbon Riders 5420 Beckley Road, Suite 334 Battle Creek, Michigan 49015
ACCEPTANCE to the PROGRAM: You will receive an email when you have been approved.
_____________________________________________________________________________________________ The Pink Ribbon Riders may also: The Pink Ribbon Riders organization can choose to donate funds to volunteer/ grass roots support groups or programs that provide direct services or support to breast cancer patients. (funds permitting) Pink Ribbon Riders may also seek out breast cancer patients in communities by contacting physicians and treatment centers in which awareness appearances are made to provide assistance for patients annually. (funds permitting). In order for the Pink Ribbon Riders to best help as many men and women diagnosed with breast cancer as possible the following items will be limited/ capped: -Life time financial assistance $1,000. -Once a year
assistance is capped at $500.00. *ADDITIONAL Organizations who may be able to provide assistance, *For assistance in Canada please see the Kelly Shires Foundation. DISCLOSURES: * The Pink Ribbon Riders do have the right at anytime to make changes to the application process should there be a need from the Pink Ribbon Riders organization. The Pink Ribbon Riders is a small volunteer based organization. *If you are a doctors office or social worker with questions about our program, please contact us first before having patients apply. As a very small organization we would love to talk with you first. Please be considerate to your patients time, by contacting us about our program. The Assistance Program has helped more than 125 men and women the first year of the program to date.
|
||||||
|