Our valued partners

Submit an application on behalf of your patient today. We only accept referrals from social workers, nurse and patient navigators, community health workers, and health care providers. We are ready to assist your patients who need help meeting daily living expenses.

"We are grateful for the support Shades of Pink Foundation provides to our patients. The online application is easy to navigate and the turnaround time for financial assistance is quick."

 — Brenda S.

NEW EXPANDED ELIGIBILITY

Breast cancer patients who live outside of our service area in Southeast Michigan*, but are undergoing active treatment at a hospital system or facility within one of the nine counties listed below, are eligible to submit an application through their health care provider.
*Genesee, Lapeer, Livingston, Macomb, Monroe, Oakland, St. Clair, Washtenaw, and Wayne counties.

You are our valued referral partners in identifying individuals undergoing breast cancer treatment who are in financial need. Please visit our Assistance tab for detailed information on qualification criteria and our application process. The application must be completed and submitted by you on behalf of your patient.

We will review the application promptly and take it from there. With you as our partner, we can make a difference for those struggling to pay daily living expenses.

We proudly serve breast cancer patients across Southeast Michigan, which includes Genesee, Lapeer, Livingston, Macomb, Monroe, Oakland, St. Clair, Washtenaw, and Wayne counties.

Covered expenses include, but are not limited to:

  • Mortgage/Rent

  • Utilities

  • Car payments

  • Insurance premiums

  • Transportation

  • Licensed childcare costs

Applications must be submitted online via the electronic form by a health care professional only (social worker, patient navigator, community health worker, oncologist, nurse, etc.).

Please read all instructions below:

  • A printable version of the Financial Support Application is available below for "working" purposes only, so that information can be compiled easily by the patient and referral partner prior to electronic submission. The patient should fill out a hard copy of the application and sign it before sharing the document with their health care provider. The provider should scan and save a hard copy of the patient's application for their records.

  • When the patient meets with their health care provider, the information in the hard copy of the application will then be transferred into the electronic version of the application by the patient’s referral partner. The patient can either sign the electronic version, if present, and/or their health care provider can sign on their behalf.

  • All applications must be submitted electronically by a health care professional using our Online Financial Support Application (available at https://app.goformz.com/s/3DcXjZv6ioSSEOAUF4BA). This printable version is for "working" purposes only.

  • Referral partners are unable to save the online application and resume filling the form out later. Please be sure all information is ready to input electronically when opening the online form.