2019 Breast Reconstruction - Charitable Care Application

Overview

The Plastic Surgery Foundation (PSF) is committed to supporting organizations that provide charitable care to women seeking breast reconstruction surgery who are in financial need. Through The PSF’s Breast Reconstruction Awareness Fund, The PSF awards a limited number of Charitable Care Grants to U.S. based, tax-exempt public 501(c)(3) charities that have demonstrated a commitment to providing breast reconstruction surgery charity care. Involvement by an active ASPS member(s) is strongly encouraged.

Grant Cycle

Breast Reconstruction Awareness Fund Charitable Care Grant applications for the 2019 grant cycle will be accepted through Thursday, April 4, 2019. All applications must be submitted by Thursday April 4, 2019. Announcements of grant awards will be made in July of 2019.

Funding

Breast Reconstruction Awareness Fund Charitable Care Grants, up to $15,000, are awarded to U.S. based tax-exempt public 501(c)(3) charities that have a demonstrated a track record of providing effective breast reconstruction surgery charity care. Grant funds must be used only for surgical care expenses for women having breast reconstruction surgery, particularly for uninsured and underinsured women in underserved communities. Funds from this grant cannot be used for Plastic Surgeon physician surgical fees or cancer care.

Click here for allowable and non-allowable expenses.

Upon approval of grant funding, funds will be dispersed according to the agreed upon Breast Reconstruction Awareness Fund Charitable Care Grant Agreement.

Funding Period

Grants will be awarded for the period beginning July 1, 2019 and ending June 30, 2020 and must be used to support surgeries or care that occurs within this timeframe.

Organization's Name: *

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Main Contact: *

First Name Last Name

Organization's City, State: *

E-mail *

Phone Number *

- Area Code Phone Number

Total Amount Requested: (Not to exceed $15,000) *

Do you have an ASPS member(s) participating in this project? If so please provide name(s) and ASPS ID. *

What percentage of your organization's current activities are specifically focused on providing breast reconstruction care? *

How many breast reconstruction charity care procedures has your organization supported over the last three years? *

How many years has your organization participated with Breast Reconstruction Awareness (BRA) Day? *

Is your organization a Breast Reconstruction Awareness (BRA) Day "Affiliate"? (www.BreastReconUSA.org/events) *

Yes No

Have you applied for a PSF Breast Reconstruction Awareness Fund Grant in the past? (Select all that apply) *

Yes - Charitable Care Grant Yes - Public Awareness Grant No

Have you ever received a PSF Breast Reconstruction Awareness Fund Grant in the past? (Select all that apply) *

Yes - Charitable Care Grant Yes - Public Awareness Grant No

Please provide a description of your organization's current commitment to the treatment of breast reconstruction patients, particularly those in low and moderate income households. Include historical details on how your organization has provided free or reduced price care in the past. *

Provide a detailed outline of your proposed program for which you are seeking funding, including how the program will provide breast reconstruction services. *

PROGRAM BUDGET: Provide a proposed budget totaling the amount requested broken down by patient. Please include any details on which services will be donated, or offered at reduced prices. Budgets should ONLY be for Breast Reconstruction Related Expenses and not to be combined with Breast Cancer expenses. (ex: mastectomies)

Important: Please click the link for allowable and non-allowable expenses:

https://www.thepsf.org/documents/Programs/Grants/BRAfund-Charitable-Care_Allowable-Expenses.pdf

IMPORTANT: Please upload all attachments as PDFs and label clearly to indicate the required documents you are submitting. EXAMPLE: "Proposed Program Budget_(organization name)"

Upload Program Budget Here: *

How many women do you expect will receive care from this award? *

How many women do you expect will receive breast reconstruction surgery due to this award? *

How many women, if any, do you expect to educated about breast reconstruction due to this award? *

List the names and ASPS ID's for each Plastic Surgeon who will be involved in the charity care of patients benefiting from this grant. Include the number of breast reconstruction surgeries performed annually for the past three years for each Plastic Surgeon.

Upload a biosketch for each Plastic Surgeon that will be involved in the charity care *

Upload a File

What geographic areas does your organization serve? Please describe the need within this area. *

Patient selection criteria: Describe below how your organization determines which patients are eligible for charity care and how they are selected to receive charity care. Provide details about the eligibility criteria used to select individuals to receive breast reconstruction surgery charitable care and process for verifying patient financial need. Demonstrate that the beneficiaries are from low to moderate income households, including the percentage of recipients. *

Does this proposed program target a community/population that has not yet been reached through existing initiatives; or use new or innovative approaches to reaching its target population? *

Does the program include any implementation strategies, including fundraising efforts, that will help sustain the activities after the completion of the funding period? *

Provide a description of the anticipated benefit that this award will have on your organization, breast reconstruction patients and your community. *

How will you recognize The PSF within your proposed grant program? If past awardee, how have you recognized The PSF in your promotional materials, website, etc.? *

Upload a current list of Board of Directors here. *

Do you have an IRS Section 501(c)(3) Exemption Letter *

Yes No

Upload your Exemption Letter here.

Do you have your most recent IRS Form 990? *

Yes No

Upload your 990 Form here.

Do you have your most recent audited financial statements? *

Yes No We are exempt

Upload audited financial statements here.

Upload your organization's current annual budget here. *

Please upload for any additional information, pictures, examples, etc you wish to provide.

Upload a File

Contact

For additional information about the Breast Reconstruction Awareness Fund Charitable Care Grant, please contact:

The Plastic Surgery Foundation

Attn: Mary Ruth Arway, MA

Research Grants Project Manager

444 E. Algonquin Road

Arlington Heights, Il 60005

rarway@plasticsurgery.org

research@plasticsurgery.org

https://www.thepsf.org/programs/breast-reconstruction-awareness-campaign

847-228-3317