STEP 1: Complete ALL sections of the Pink Assistance Fund (PAF) Application Form

STEP 2: Complete and sign the Release & Authorization

STEP 3: Complete and sign the Story Release

STEP 4: Upload ALL the following required documents to the application:

a. Proof of Loudoun County residency (either copy of state issued ID, driver’s license or bill in YOUR NAME with Loudoun County address on it)
b. Print Physician’s Verification form (download and print now) and have your physician’s office complete. You can either scan and email or mail once completed.

STEP 5: Mail everything not uploaded below and completed Physician’s Verification form (if
not emailed) to:

LBHN/PAF Program
P.O. Box 6154
Leesburg, VA 20178

Once your application has been received, LBHN will contact you within 7-10 days to set up a personal interview. If you are unable to obtain the documents requested or have any questions regarding the application process, please email LBHN at pafinfo@lbhn.org.

Note: failure to provide the needed documentation will result in a longer processing time.

The amount/type of financial assistance provided to patients is determined by funds available and is on a case-by-case basis.

Types of assistance available:

• Medical – bills, insurance co-pays, insurance premiums, prescriptions and medical procedures/treatments
• Transportation – car payments, car insurance, gas cards
• Utilities – gas, electric, water
• Food – grocery cards
• Housing – assistance with rent/mortgage payment
• Personal Care – prostheses, wigs, bras
• Other items as needed