Pink Assistance Fund (PAF) Application

For Loudoun County Breast Cancer Patients

STEP 1: Complete ALL sections of: Pink Assistance Fund (PAF) Application Form below – or – click here if you would prefer to download/print the form and mail in.

STEP 2: Upload ALL the following required documents to the application:

a. Copy of driver’s license or proof of residence (i.e. utility bill in your name listing address)
b. Physician’s verification form (page 4)
c. Attach copies of all bills you would like considered for payment (i.e. medical, mortgage
statement, rental agreement, car loan, insurance premiums, etc.)

STEP 3: Complete and sign the Release & Authorization Below

STEP 4: Download and Print the Physician’s Verification Form – Have your physician’s office complete and sign Physician’s Verification Form

STEP 5: Mail everything not uploaded below, and the completed Physician Verification Form 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