Applications and Client Contact Information

• MHC logo_FINAL 2013

 Due to the pandemic, My Hope Chest has extremely low funds but we are helping as many that come to us as we are able.  Please submit your application so you get on our waitlist and follow up with us frequently.  We know this is a temporary situation.  Thank you for your interest.

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 My Hope Chest’s Application

process has Two parts…

please read carefully…

1. ONLINE APPLICATION- 1 page

Submit the Form Online (English)

Solicitud en línea del paciente (Spanish)

2. AGREEMENT FORM

Client Agreement Form

Client Media Release

3. BREAST RECONSTRUCTION SURVEY – You are required to participate. CLICK this important Survey to help us gather data about the size of the problem uninsured or underinsured women face (takes 10 minutes.)

4. Bill Pay Assistance:  If you are in active treatment, seeking assistance with non-medical bills, please email us at navigator@myhopechest.org to receive an application.

 

This is a general outline of the criteria required to be considered for the My Hope Chest Program.

Criteria

Must be 65 years of age or under, free of medical complications that would preclude safe surgery (as determined by our participating surgeons and medical consultants), able to show demonstrable need* and a legal resident or citizen of the United States.   *Demonstrable need shall include consideration of the following criteria,

  1. Uninsured or Underinsured
  2. Due to new government guidelines, applicants must have applied for insurance through the Marketplace.  Proof of acceptance or denial is required.
  3. Proof of non-eligibility for Medicaid annually
  4. Income that does not support self- funding of care
  5. Hardships or exceptional circumstances.

Versión en español:

Debe ser menor de 70 años de edad/ debe tener o ser menor de 65 años de edad, libre de complicaciones médicas que impidieran una cirugía sin riesgo/s (según sea determinado por nuestros cirujanos participantes y asesores médicos), capaz de demostrar la necesidad*, y ser ciudadano estadounidense o residente legal.
*La necesidad demostrable incluirá el siguiente criterio:

  1. no tener seguro médico,
  2. comprobante que no califica para el seguro Medicaid,
  3. ingresos que no sustenten el auto financiamiento del cuidado de su salud,
  4. adversidades económicas o circunstancias excepcionales.

If you are unable to fill out the application online…

  • **Download and print a PDF of the Client Application in English or Spanish here- Remember the Client Agreement Form and Media Release.
  • Upon completion of your application please mail to: 4579 East Spruce Drive Dunnellon, FL 34434

Please direct your questions to

Client Navigator @ (727) 488-0320 from 9am-9pm EST

or email navigator@myhopechest.org


It is our goal to serve as many survivors as possible as quickly as possible. However, we do have a waitlist nationally. We encourage you to seek help through your local community or University hospital and reach out to “breast care centers” within these hospitals as they may have funds set aside for “uninsured” individuals.

Most importantly, as a grassroots organization, we need you to help US help YOU! Get involved to help raise awareness of your problem by sharing MY Hope Chest’s information in your community, with your newspapers and local groups-  Blog about us and add it to your Facebook and all social media.

Help us change lives… Pay it Forward….Contact us at info@myhopechest.org to learn more.