Applying For Help

*Please note that Pin Me Pink, Inc. cannot provide immediate emergency funds.


Pin Me Pink, Inc. is a nonprofit organization established in 2017 dedicated to providing emotional empowerment as well as physical support to those touched by breast cancer between the ages of 18 and 45.
     

Pin Me Pink, Inc. Breast Cancer Qualifying Guidelines

Pin Me Pink, Inc. will be offering assistance for projects pertaining to breast cancer education, outreach, treatment and support services in the Philadelphia, Washington DC, Maryland and Virginia areas effective 2018. 

  • Pin Me Pink, Inc. Application 
    • Application for Assistance
    • Medical Information 
    • HIPAA Privacy Authorization Form
    • Media Release and Waiver 
  • A signed and dated letter, on letterhead, verifying your current diagnosis and detailing your treatment plan from one of the following: Oncologist, Patient Advocate, or Nurse Navigator.
  • A copy of your driver’s license or State ID Please note: the address on your ID must match the address on your application form.


Requirements for Financial Assistance include  following (if approved):

Copies of utility bills you wish to have considered for payment. The bills must show your name, your current address, the account number, the current balance due, and the complete address to which payments are sent.


Please DO NOT send originals.

  • Bills considered for payment:
    • Utility Bills; Electric, Gas, and/or Water only


*IF YOU RENT, you must send a complete copy of your lease/rental agreement, including the name and address of the person or agency to which payments are made. We must have a current email address at which to contact you. If you do not have an email address our communication this will delay the processing of your application.