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PO Box 51592, Durham, NC 27717-1592

919.490.1571

BREAST CANCER ASSISTANCE PROGRAM (BCAP) APPLICATION

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Dear Applicant:


The Breast Cancer Assistance Program (BCAP) provides assistance to women facing financial challenges after diagnosis. This program provides free mammograms and financial support for: medical related lodging, co-pay, office visits, prescriptions and transportation.

The form below must be completed and submitted with the REQUIRED SUPPORTING DOCUMENTS (i.e., medical bills, rent receipt, utility bill, etc.). Upon completion and submission of the form, the application process takes a minimum of 7 business days, incomplete application will be returned and will delay any decision regarding assistance.

If your application is approved you are required to do the following:

  • Submit a statement of testimony to SNI which may be posted on our website within 2 weeks or sent to funders
  • *Contact your local Sisters Network Chapter and become an active or associate member. *If a chapter is located in your area.
  • If these requirements are not met you will be ineligible to apply for future funding.

    It is our goal to assist you financially during your journey. Sisters Network® Inc. (SNI) is a leading voice and only national African American breast cancer survivorship organization in the United States. Our purpose is to save lives and provide a broader scope of knowledge that addresses the breast cancer survivorship crisis affecting African American women around the country.

    Wellness,

    Valarie C. Worthy, President Sisters Network Triangle NC


    BREAST CANCER ASSISTANCE PROGRAM (BCAP) APPLICATION
    If approved, financial assistance payments may be made directly to the Provider.
    Submission of this application does not imply nor guarantee approval of Financial Assistance
    PLEASE COMPLETE THE ENTIRE APPLICATION(PRINT CLEARLY)

    *Denotes a required field

    PERSONAL INFORMATION

    Today's Date*: First Name*: Last Name*:
    Current address*:
    City*: State*: ZIP Code*:
    Contact Number*: Email:
    Date of birth* (M/D/Y):
    Are you a member of a Sisters Network Affiliate Chapter?* YES NO    If yes , what chapter?
    Approved by Chapter President
    Have you received BCAP in the last 12 months?* Yes if yes $ No
    ASSISTANCE REQUESTED*
    Office Visits Co-pay Medical Related Lodging Transportation Prescription Mammogram Other
    (please describe)
    TREATMENT INFORMATION
    Stage at Breast Cancer: Age at Diagnosis:
    Treatment:
    Are you currently in treatment? Yes No If Yes,Treatment dates: Start:Finish:
    FINANCIAL STATUS
    Are you currently employed?* Yes No If NO, state reason:
    List sources of income:
    Amount of Request*: $ Head of Household Yes No Number in Household:
    Annual Household Income* under $25,000 $25,000-$49,999 $50,000-$69,000 $70,000+
    Explain circumstances creating financial need at this time*:
    UPLOAD SUPPORTING DOCUMENTS*
    Formats accepted (.doc , . pdf , .jpg , .gif)
    HOW DID YOU HEAR ABOUT SISTERS NETWORK INC.? (REQUIRED INFORMATION)
    Referred by:
    Did referring Organization give you any assistance?: Yes No If yes, list type of assistance and amount:
    Contact Name: Contact Email
    Contact Phone
    Office Use Only: Date Rec'd: Scan Date: Staff:
Sisters Network Triangle NC 2016