BREAST CANCER ASSISTANCE PROGRAM (BCAP) APPLICATION If Approved, Payments are made directly to the Provider. Submission of this application does not imply or guarantee approval of financial assistance. APPLICANTS CAN ONLY RECEIVE FUNDING ONCE A YEAR Personal Information (Print Clearly) Today’s Date: Are you a member of a Sisters Network Affiliate Chapter? □ Yes □ No If YES, what chapter? First Name: Last Name: Date of birth (MM/DD/YYYY): Phone: Email: Current address: City: State: Zip Code: Medical Insurance: □ Yes □ No If Yes: □ Private/Commercial □ County/State □ Medicaid □ Medicare □ Supplemental Insurance A □ Suppliemntal Insurance B Name of Insurance Carrier: RACE/ETHNICITY INFORMATION: (Check one) Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander White Hispanic or Latino ASSISTANCE REQUESTED (PLEASE SELECT ONE) Please provide the below information to the support the bill you are submitting: Have you received BCAP in the last 12 months? □ Yes □ No What Type? How Much? Utilities FINANCIAL REQUEST PROVIDER Medical Bill FINANCIAL REQUEST PROVIDER Rent FINANCIAL REQUEST PROVIDER Mortgage FINANCIAL REQUEST PROVIDER FINANCIAL STATUS
Cancer Program is dependent upon the allocation of Sisters Network resources to the Breast Cancer Assistance Program within Sisters Network annual budget. Sisters Network Board of Directors has exclusive determination as to those monies and resources. Selection Process: The BCAP application, including the selection of the successful applicant is reviewed by the BCAP Survivor Committee. The Survivor Committee meets throughout the year to consider completed and qualifying BCAP Applications. Sisters Network and the Survivors Committee reserve the right to decline a request, and/or partially grant a request based upon the allocation of funds to the program. REVIEWING OF THIS APPLICATION DOES NOT CONSITIUTE ANY PROMISE OR ASSURANCE BY SISTERS NETWORK (OR ANY OF ITS REPRESENTATIVES) TO AN APPLICANT REGARDING THE GRANTING OF THEIR REQUEST. Grants of Rights, Restrictions on Use: The information provided by applicant herein will only be utilized for Sisters Network Inc. consideration of your BCAP Application. Your information will not be shared with anyone unaffiliated with Sisters Network. Should your request be granted, Sisters Network will not communicate with any third parties relating to your request without your prior consent. Sisters Network reserves the right to utilize your Breast Cancer Assistance Program experience to share with potential sponsors as well as the general public in order to promote the Breast Cancer Assistance Program to other women cancer survivors that could potentially participate in this program. Sisters Network reserves the right to terminate the Breast Cancer Assistance Program at any time due to budget restraints or unmitgating cirmcumstances. Time Frame of Process: The complete review /approval process takes approximately 30 business days from the date that Sisters Network Inc. received the entire BCAP application package. BCAP 2015 APPLICATION PERIOD ENDS ON NOVEMBER 13, 2015. BCAP 2016 APPLICATION PERIOD IS FROM FEBRUARY 1, 2016- NOVEMBER 11, 2016 I affirm that I have read the all of the above important information, and attest that the information provided by me in this application is true and correct to the best of my knowledge. Applicant Signature: ____________________________________________________________ Printed Name: _________________________________ Date Signed: ___________________