Assistance Application

Please fill out the form below and submit to apply for assistance.

In order to be eligible for limited financial assistance you must: Have a diagnosis of breast cancer confirmed by an oncology health care provider- Be in active treatment for your breast cancer - Be a U.S. Citizen
- I agree
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Marital Status
- Single
- Married
- Divorced
- Legally Separated
- Widowed
I declare that the above information and the accompanying physician verification/documentation that I am actively receiving treatment for Breast Cancer is true, complete, and accurate. I understand that submitting false or misleading information on this application is a crime punishable under state and federal law. I also understand that if any documents are found to be incorrect, incomplete, false, or misleading, I will be required to repay all assistance received from Pink Fishing, Inc. plus interest. This certification authorizes Pink Fishing, Inc. to verify with my Oncologist that I am actively receiving treatment for Breast Cancer. This authorization to release information is confirmed by the signature below. This authorization shall become effective immediately and shall remain in effect for one year from the date of signature or until Pink Fishing, Inc. has ceased providing services to you, whichever is longer. I reserve the right to withdraw this authorization at any time by written notification to Pink Fishing, Inc.. I understand that revocation of this authorization will not affect any action Pink Fishing, Inc. took in reliance on this authorization prior to Pink Fishing, Inc.’s receipt of my written notice of revocation.
- I accept
As an applicant for assistance, you will be asked to share some of your medical information with Pink Fishing, Inc. Your medical. information is protected by law and can only be shared with your permission. This information includes social security number, full legal name, address, phone number, marital status and physician verification of actively receiving breast cancer treatment
- I understand and agree
I fully understand and consent to such disclosures of protected health information and the terms of this consent.
- I agree

Please fill out the form below and submit to apply for assistance.

You can also print out the form here and mail it to: Pink Fishing, Inc. PO Box 1445 Copperas Cove, TX 76522

You can also print out the form here and mail it to:
Pink Fishing, Inc.
PO Box 1445
Copperas Cove, TX 76522