*Pink Hands of Hope is a non-profit organization whose mission is to assist people battling cancer. The Helping Hands program is designed to help patients with mounting medical bills. Approval of applicants is based on availability of funds for this program.

You must reside in one of the participating counties, Adams, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lancaster, Lebanon, Perry, Schuylkill, Snyder, or York.

Step 1: If you are a cancer patient with unpaid medical bills (not covered by insurance or grants), please complete the online application. If you prefer, you can DOWNLOAD the application and return it by email or regular mail.

Step 2: Once the application is received and reviewed, it will be forwarded to the Pink Hands Board of Directors for approval (based on availability of funds) up to $1500. Please note this step is completed within a very short period.

Step 3: When the approval is complete, you will be contacted by Pink Hands of Hope to discuss payment of the outstanding medical bill(s).

Step 4: Once we have received the copies of the outstanding medical bills, Pink Hands will cut check(s) directly to your provider.

If you have any questions regarding this application process, or any other questions for Pink Hands of Hope, feel free to email us at info@pinkhandsofhope.org or call at 717-620-8264.

HELPING HANDS APPLICATION

APPLICANT INFORMATION

First name

Last name

Street Address

City

State

Zip Code

Phone

Date of Birth

Who referred you to Pink Hands of Hope?

DIAGNOSIS AND HEALTH INSURANCE INFORMATION

Type of Cancer

Date of Diagnosis

Treatment Doctor/Surgeon

Doctor/Surgeon Phone Number

Doctor/Surgeon City

Primary Oncologist

Oncologist Phone Number

Oncologist Street Address

Oncologist State

Oncologist Zipcode

Do you have health insurance

Yes

If yes, please indicate name of primary insurance:

FINANCIAL INFORMATION

Has your diagnosis affected your ability to remain employed?

Yes

How many unpaid MEDICAL BILLS do you currently have outstanding? ( Please list debtors and amounts below, include out of pocket treatment, prescription, etc.)

By signing below, you give permission to Pink Hands of Hope to contact your medical professionals regarding your

medical and financial information:

Signature

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