Application

Contact Information

First Name

Last Name

Email Address

home Phone

Mobile Phone

Work Phone

Emergency Contact

NamePhone NumberHow are you related?

Residential Address

Street Address

City

State

Zip Code

How long have you been a full time resident in your state and city?

Mailing Address

Same as Residential Address

Street Address

City

State

Zip Code

Personal Information

Which of the following groups do you feel you belong to?

Other

Marital StatusSingleMarriedDivorced

Responsible Party

First NameLast NameHome PhoneStreet Address

City

State

ZIP Code

Social Security NumberLast 4 Digits

Marital StatusSingleMarriedDivorced

Date of Birth

SexFemaleMale

Income

Annual IncomeSource of IncomeEmployer's NameEmployer's AddressEmployer's Phone NumberIf unemployed, for how long and why?

Medical Insurance

Do you have Medical Insurance?YesNo

Have you applied for insurance through the Affordable Care Act?NoYesApproved (Please list below)YesApplication PendingYesDenied (Please explain below)

Reason Insurance DeniedInsurance Name

Have you applied forMedicaidSocial Service ProgramOther Please specify belowI have not applied to any social services programs

What Program?When did you apply?

Application Status

Medical History

Have you seen a plastic surgeon yet? If so, who was it and what was the outcome?Additional Services Needed

If your surgery could be paid for, would you travel out of state for the procedure?YesNo

Family Members

Family Member 1

Name

Age

Insurance?YesNo

Family Member 2

Name

Age

Insurance?YesNo

Family Member 3

Name

Age

Insurance?yesNo

Family Member 4

Name

Age

Insurance?YesNo

Your Story

Please provide a brief explanation of your journey through breast cancer and why you want to have reconstruction. Please limit to 500 words or less and be sure to state your request clearly.

I AUTHORIZE MY HOPE CHEST TO USE A PHOTO OF MY CHOOSING TO HELP RAISE MONEY FOR THE NEXT PATIENT IN LINE.
*This is not a nude photo, but a photo you like of yourself.yesNo

If yes, please email picture to info@myhopechest.org and include your full name and email address

Additional Information

How did you hear about us?

If reffered from a hospital or breast center, enter facility name

If you chose "Other" please name referral source

Attestation

By filling out and submitting this form, I attest that the information provided is accurate and true to the best of my knowledge. I understand that my application is NOT complete until all of my documents are received including: 1) Patient Application 2) Patient Agreement Form and all documents and letters therein. I understand that if I have falsified this application, I will be disqualified from the program.

I Agree

Application Form

Wait List Notice

Contact Information

Emergency Contact

Residential Address

Mailing Address

Personal Information

Responsible Party

Income

Medical Insurance

Medical History

Family Members

Family Member 1

Family Member 2

Family Member 3

Family Member 4

Your Story

Additional Information

Attestation

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Application Form

Wait List Notice

Contact Information

Emergency Contact

Residential Address

Mailing Address

Personal Information

Responsible Party

Income

Medical Insurance

Medical History

Family Members

Family Member 1

Family Member 2

Family Member 3

Family Member 4

Your Story

Additional Information

Attestation

Pay It Forward!

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Applicants

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