Request for Resources Form

For care-seekers who don't need a mammogram but need additional information

Intro

Our Education and Patient Advocacy Program (EPAP) connects breast cancer patients, survivors, and the general public with lifesaving resources, educational materials, and referrals. Complete the form below if you do not need a mammogram or other screening test, and would like to be connected with resources available to you.

First Name

Last Name

Street Address

City

State

Zip Code

Phone Number

Email Address

Date of Birth

Select your age range

Ethnicity

Gender

Male Female Other

Do you have insurance? (having insurance WILL NOT disqualify you for assistance)

Yes No

If yes, what is the name of your insurance provider and your insurance plan?

Does the applicant have Medicare or a Medicare Advantage Plan?

If you're filling this out for someone else, answer for them. This will not affect the application.

Yes, Medicare Yes, Medicare Advantage No Not sure

Resource referral questionnaire

Tell us a little more about your needs...

Do you currently have breast cancer and need support?

Please write anything else you'd like us to assist with!

Consent and signature

Please answer the following and sign your name

Do you consent to receiving educational materials and content from the American Breast Cancer Foundation in the future?

Yes No

Your signature

Thank you

Thank you! We will reach out within 72 hours with a list of resources that may be able to assist you!

Thank you

I agree

By submitting this form, I consent to being contacted by ABCF and its partners about support and resources.