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Applicant Information
Please complete this form to request assistance with home-based needs during your treatment or recovery. All information provided is kept strictly confidential.
Important Policies:
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Response Time: Please allow up to 14 business days for a response.
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Household Limit: Only one request per household is permitted per calendar year.
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Approved requests are at the discretion of The Pink & The Blue Breast and Prostate Cancer Foundation.
1. Purpose: Confirm medical necessity for services.
2. Right to Revoke: Right to revoke in writing at any time.
3. Expiration: Valid for one year unless specified.
I confirm that no other member of my household has applied for or received support through this program in the last 12 months. I understand that assistance is limited to one request per household per year.I acknowledge that all approved requests are at the sole discretion of The Pink & The Blue Breast and Prostate Cancer Foundation.
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