Need Help?

Breast cancer is expensive. Our mission is to help women by providing financial assistance. Whether you’ve just been diagnosed, or you’re managing long-term side effects, you may apply for help from Pink Hugs.

To request assistance, please complete this form and email it to Pink Hugs (click link below.)
We will also need your signed HIPAA Release of Information form before we can review your application.

Your Application and HIPAA release form received by the 15th of the month will be considered for the following month’s distribution. If Pink Hugs can help you, we will contact you promptly.

Name:
Date of Birth:
Street Address:

When were you diagnosed with breast cancer?
What stage?
Where were you treated? (Cancer center, hospital system etc.)
What was your treatment plan? (Please check all that apply)ChemotherapyRadiationLumpectomyMastectomy
When did you complete your treatment?

Please explain why you need financial assistance currently.
What is your most urgent, specific financial need?
Amount requesting:
If there is anything else you would like us to know, please tell us here:

Pink Hugs wants to help as many women as possible. Our funds and the number of applications we receive each month will determine how much we can help.