Our main mission is to help patients in need. If you would like to be considered for funding please fill out the form below. We also ask you to download and print out the Authorization for Disclosure form and submit it with a letter from your family doctor or oncologist, stating you are currently receiving treatment for breast cancer. All three forms are required before we can proceed with any form of payment.

You can mail the forms to:
Help The Fight
143 Oakridge Drive
Mountville, PA, 17554

Funding Form Request

Date
Date
$
Patient's Name *
Patient's Name
Date of Birth *
Date of Birth
Address *
Address
Phone Number *
Phone Number
$
e Signature *
e Signature
e Signature is required to finalize application

Please click on the Authorization For Disclosure form below to download and print: