I understand: -that to receive a grant voucher from this program to assist with the diagnosis of or ruling out of breast cancer, I must submit the following. If I do not submit this within 30 days this application will expire and I may have to start the application process over. Expired applications may result in being denied for future applications and grants. Signed/Dated Application Form Referral/Order/Prescription Form from a physician (doctor), nurse practitioner, or physician’s assistant indicating the need for breast imaging Proof of Residency (license, state ID, utility bill, medical bill, U.S. passport, Visa, residency papers, rent/mortgage document) -that the information I provided above to determine my eligibility for this program is true and accurate. I have made changes to the application if the information is not accurate. Falsifying information I have provided to ABCF to determine my eligibility will require me to forfeit any grant awarded to me through this program and I may be denied for future applications and grants. -that this program requires proof of residency to process my application. I will choose a form of proof of residency accepted by ABCF to send with my completed application packet. ABCF does not accept, nor is responsible for original documents. -that the funds awarded to me in my grant voucher are to HELP with SOME of the costs of the approved test(s) only. ABCF grants do not provide free breast imaging. Additional CADS, radiology reading fees, pathology fees, etc. are not included. I am responsible for all such fees and any costs which exceed the grant award amount. -that ABCF will pay grant monies awarded me directly to my health care provider only. While my healthcare provider may submit a detailed copy of bills in which I am requesting to be paid from my grant, I am solely responsible for making sure the bills from my test(s) are received by ABCF before the grant voucher expiration date or they will not be paid. The
I understand: -that to receive a grant voucher from this program to assist with the diagnosis of or ruling out of breast cancer, I must submit the following. If I do not submit this within 30 days this application will expire and I may have to start the application process over. Expired applications may result in being denied for future applications and grants. Signed/Dated Application Form Referral/Order/Prescription Form from a physician (doctor), nurse practitioner, or physician’s assistant indicating the need for breast imaging Proof of Residency (license, state ID, utility bill, medical bill, U.S. passport, Visa, residency papers, rent/mortgage document) -that the information I provided above to determine my eligibility for this program is true and accurate. I have made changes to the application if the information is not accurate. Falsifying information I have provided to ABCF to determine my eligibility will require me to forfeit any grant awarded to me through this program and I may be denied for future applications and grants. -that this program requires proof of residency to process my application. I will choose a form of proof of residency accepted by ABCF to send with my completed application packet. ABCF does not accept, nor is responsible for original documents. -that the funds awarded to me in my grant voucher are to HELP with SOME of the costs of the approved test(s) only. ABCF grants do not provide free breast imaging. Additional CADS, radiology reading fees, pathology fees, etc. are not included. I am responsible for all such fees and any costs which exceed the grant award amount. -that ABCF will pay grant monies awarded me directly to my health care provider only. While my healthcare provider may submit a detailed copy of bills in which I am requesting to be paid from my grant, I am solely responsible for making sure the bills from my test(s) are received by ABCF before the grant voucher expiration date or they will not be paid. There are absolutely no exceptions to this deadline. -that by using this program, I give permission to my healthcare provider or other program(s) to share information with ABCF concerning my itemized bill(s), test results, procedure(s), diagnosis, and related care that result from my participation in this program. This information will be used to authorize additional grants, grant payments, statistics, and for program quality control only and will never be published or distributed with my name attached unless otherwise approved by me. -that by signing and dating this application, I am confirming that the information I provided is correct and that I have read and understand the guidelines to complete this application process and receive financial assistance from ABCF.