Breastoration, Inc Application

1

This application allows you to save your progress. Once you answer enough questions, the save icon will appear (it will appear in grey at the bottom of the form). Ensure that you have entered an email address that you will have access to. When saving the file, please use the "Skip Create an Account" option if prompted. Once you receive your email with the link, don't lose it. You will need it to pick back up where you left off.An image of the progress indicator and save icons.

2

Please enter your email* This field is required.

example@example.com

3

I have reviewed the Breastoration FAQs and will comply with those guidelines.* This field is required. Breastoration (FAQ)

I have reviewed the linked information and agree

4

Phone Number* This field is required.If no phone number, enter 555-555-5555

Please enter a valid phone number.

5

Have you ever applied for Breastoration services before?* This field is required.This helps prevent duplicate accounts. It does not affect your ability to get Breastoration services.

YESNO

6

Have you previously submitted a Breastoration application in the last 12 mounts?* This field is required.This question allows us to better process your Breastoration application.

YESNO

7

Please enter personal information in the spaces below* This field is required.When entering your name, please enter your full legal name as it appears on your driver's license or Government/Stated issued document(s)

Gender

First Name

Middle Name

Last Name

Address Line 1

City

State (Select your state from the dropdown)

Zip

8

Date of Birth* This field is required.

Date

9

Parish/County* This field is required.Just enter the name of the Parish/County. No need to add parish/county after the name.

10

Race (please check one)* This field is required.This is used for statistical purposes.

American Indian or Native Alaskan

Asian

African American

Hispanic or Latino

Native Hawaiian or Pacific Islander

White/Caucasian

Other

11

Marital Status* This field is required.This is used for statistical purposes

12

Household Makeup* This field is required.This is used for statistical purposes

13

Number of dependents between the newborn and 5 years * This field is required.Enter 0 if this does not apply to your family situation. This is used for statistical purposes

14

Number of dependents between the ages of 6-12 years * This field is required.Enter 0 if this does not apply to your family situation. This is used for statistical purposes.

15

Number of dependents between the ages of 13-18 years * This field is required.Enter 0 if this does not apply to your family situation. This is used for statistical purposes.

16

Number of dependents between the ages of 18 -26 * This field is required.Enter 0 if this does not apply to your family situation. This is used for statistical purposes.

17

Annual Income* This field is required.If your household income is above 500% of the Federal Poverty Level, un-covered medical costs must be equal or greater than 10% of your income. Please include this information in your personal story. Federal Poverty levels can be found at: Poverty Guidelines | ASPE

Enter Income without a comma and dollar sign, ex 6500. If no income, enter 0

18

If income is $0, select from the drop down menu.* This field is required.Select the best option from the drop down menu.

19

Your Occupation and or the name of your Employer* This field is required.If unemployed, enter former employer name or former occupation

20

Expected time you will be unable to work due to reconstruction/recovery* This field is required.If unemployed, enter unemployed.

21

Estimated loss of income during recovery. If unemployed, indicate the estimated income loss that will happen to a caregiver that does not live with you but taking off work to assist in your recovery.* This field is required.Enter Income without a comma and dollar sign, ex 6500.

22

Do you currently have health insurance* This field is required.

23

Date of MastectomyThis can be a future date.

Date

24

Date of reconstruction

Date

25

Date of most recent revision, if applicable

Date

26

Surgery Facility* This field is required.Name of the facility where your surgery will take place

27

Surgeon's Name* This field is required.Enter the name of the surgeon who will be doing your surgery

First Name

Last Name

28

Social Worker/Case Manager's namePlease enter the social worker/case manager's name if you have one. Otherwise, please leave blank.

First Name

Last Name

29

Patient Story* This field is required.Review and select an option from the drop down.

30

Section 1. * This field is required.If you selected upload previously created patient story documents, then use this section. Otherwise, move to the next section. Your story of diagnosis, reconstruction. Use this section if you have already created documents that can be uploaded. Please include things like how much work you've missed, non-medical expenses you've incurred as a result of your surgery such as travel. This information will be sent to our Breastoration Committee so that they can review your request.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

31

Section 2* This field is required.Manual Entry of Patient Story: Breastoration does not approve grants to pay general bills. Describe the temporary reconstruction-related financial impact. If you use this section, you must include non-medical expenses incurred as a result of your surgery, such as travel, lodging, meals, childcare, temporary caregiver assistance, spouse/household unpaid leave, etc.

32

For the next section, the Reconstruction Plan is needed. If you need one for your surgeon, use the link below. If not, this section can be skipped.

Reconstruction Plan (aka Surgeon Form)

33

Reconstruction Plan (aka Surgeon Form)* This field is required.If you need a copy of the form to provide to your physician, here is the link: Physician Verification Form

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

34

Proof of Income (W-2, Tax return, last 3 paychecks)* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

35

Proof of expenses (utility bills, mortgage/rent, travel costs, childcare costs)* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

36

Please upload any additional supporting documentation, if needed.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

37

1. I certify that the information provided is true and complete to the best of my knowledge.

2. I understand that incomplete applications will not be reviewed.

3. I understand that physician verification alone does not constitute an application or guarantee funding.

4. I understand Breastoration assistance is limited to reconstruction-related access and recovery needs.

5. I understand that Breastoration does not pay hospitals, physicians, insurers, or medical providers directly.

6. I authorize Breastoration to review my application and supporting documents.

7. I understand that Breastoration has final authority to approve, deny, or modify and grant the request.

8. I understand Breastoration’s grant application process is a blind process; the grant committee will not receive your name or address.

By clicking "Next" I certify and agree to all of the above.

38

Client Signature* This field is required.If you type your signature, it is considered the same as if you manually signed the application.