ACS/YAG BIOPSY ASSISTANCE PROGRAM

BIOPSY ASSISTANCE PROGRAM

During Breast Cancer Awareness Month 2021, YAG Foundation is offering financial assistance for biopsies to uninsured and underinsured women of the USVI, thanks to a grant provided by the American Cancer Society.
Contact Information
Name

First NameLast Name
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
I am uninsured/underinsured and/or have no medical benefits taken from my employer employer name if applicable field.
Do you have any other forms of insurance?

MedicaidMedicareOther
If other, please explain
What other financial help resources have you applied for and what was the determination?
Have you been approved for assistance for any other amount?
Informed Consent Agreement

Please review and digitally sign the Informed Consent Agreement.
General Understandings: I, the undersigned, understand and accept the following: This program only assists in the cost of my diagnostic biopsy. Imaging Center, PC (ICPC) will perform my services and answer questions I may have. This program does not fund additional medical examinations or pathology services. If my biopsy is positive for breast cancer, significant atypia or a papilloma, I should consult a surgeon and/or oncologist for treatment.

Confidentiality and Communication: ICPC will keep my medical records confidential and maintain them according to legal limits. ICPC will send screening mammogram reports to me at my US Postal Service address listed above and may send important results to me by return receipt mail. ICPC will send all of my prospective imaging and biopsy reports to my personal physician.

Disclaimer: Greater breast cancer detection occurs if I do monthly best self-exams, regular physical exams, annual screening mammograms, and all diagnostic exams that may be recommended on my mammogram reports(s).

Participation: My participation is voluntary. I accept all associated risks and responsibilities.
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BIOPSY ASSISTANCE PROGRAM

Contact Information

Informed Consent Agreement