Application for Funding

In order to be considered for breast reconstruction funding, you will need to complete the following steps:

1. Ensure that you meet the candidate criteria (below).
2. Complete and sign the Application.
3. Complete and sign the Client Agreement
4. Send all documents to:
   Evelyn's BFF
   1221 W 243rd St
   Harbor City. CA 90710

Breast Reconstruction Program Candidate Criteria

Uninsured

1. Letter from physician along with pathology reports verifying diagnosis of breast cancer.
2. Current letter of Medicaid denial for breast reconstructive surgery.
3. Copies of income tax returns for the most recent two tax years (joint return if married).
4. Three months of current bank statements.
5. Evidence of household income that is low (at or below 60% of the area median gross income) or moderate income (more than 60% but less than 80% of the area median gross income). Current limits are:
   
   

   Family Size	Low Income Limit (60% median)		High Income Limit (80% median)
   1	$28,560		$38,050
   2	$32,640		$43,450
   3	$36,720		$48,900
   4	$40,740		$54,300
   5	$44,040		$58,650
   6	$47,280		$63,000

6. One letter of recommendation supporting financial need for assistance. This recommendation can be from your doctor(s), family member(s), friend or employer confirming that you desire the breast reconstruction surgery and need financial assistance to have it.

Underinsured

1. Letter from physician along with pathology reports verifying diagnosis of breast cancer.
2. Medical expenses greater than 10% of annual income.
3. Health plan deductibles greater than 5% of annual income.
4. Copies of income tax returns for the most recent two tax years (joint return if married).
5. Three months of current bank statements.
6. Evidence of household income that is low (at or below 60% of the area median gross income) or moderate income (more than 60% but less than 80% of the area median gross income). Current limits are:
   
   

   Family Size	Low Income Limit (60% median)		High Income Limit (80% median)
   1	$28,560		$38,050
   2	$32,640		$43,450
   3	$36,720		$48,900
   4	$40,740		$54,300
   5	$44,040		$58,650
   6	$47,280		$63,000

7. One letter of recommendation supporting financial need for assistance. This recommendation can be from your doctor(s), family member(s), friend or employer confirming that you desire the breast reconstruction surgery and need financial assistance to have it.