Applications and Client Contact Information

• MHC logo_FINAL 2013

 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

2016 Client Agreement Form

2016 Client Media Release

3. BREAST RECONSTRUCTION STUDY – You are required to take the Study on our website (takes 3 minutes)  **Currently on hold.

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 Under insured
  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- don’t forget the Client Agreement Form too.

Upon completion of your application please mail to:

PO Box 3081 Seminole, Florida 33775

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 wait list 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 Facebooks asap!

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