For Dcb Records

FOR DCB RECORDS

Date service requested ______

Date service provided ______

Action taken ______

DELTA COTTON BELLES REQUEST FORM

If you have been diagnosed with breast cancer, in order to receive assistance, you must live in or receive services in one of the following counties: Bolivar, Carroll, Grenada, Humphreys, Issaquena, Leflore, Sharkey, Sunflower, Washington (MS) or Chicot (AR).

Name: ______DOB: ______Year of diagnosis: ______

Address: ______County: ______

City: ______State: ______Zip: ______

Phone (home/work): ______Cell phone: ______

Last grade completed: ______Email: ______

Ethnicity (circle one): African American Asian Caucasian Hispanic Native American

Private Health Insurance Yes / No Medicaid Yes / No Medicare Yes / No

TYPE of ASSISTANCE REQUESTED

______Post-op bra or camisole

______Breast prosthesis and/or mastectomy bra

______Lymphedema sleeve

______Wigs

______Transportation assistance for medical visits or treatments (Double Quick gas cards)

______Breast cancer support group (DCB Thrivers meet the second Tuesday of each month)

______Feel Beautiful sessions (teaching skincare, make-up application, & usage of scarves)

Submitting this application does not guarantee funding approval

Please share any details that are pertinent to your diagnosis or treatment that would help us in making a determination about the services you are seeking.

DOCTOR/PRIMARY HEALTHCARE PROVIDER VERIFICATION STATEMENT:

I verify that the person submitting this application has breast cancer.

Doctor’s Name: ______(Please Print)

Doctor’s Signature: ______Date: ______

We cannot evaluate this application without your doctor’s signature.

CONFIDENTIALITY NOTICE: The documents accompanying this transmission contain confidential health information that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so by law or regulation and is required to destroy the information after its stated need has been filled. If you are not the intended recipient, you are hereby notified that any disclosure, copying or distribution of the contents of these documents, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or destruction of these documents.

Applicant’s Signature: ______Date: ______

How did you hear about Delta Cotton Belles? ______

Where did you get this application? ______

Have you used our services before? ______If so, what was provided ______

I am willing to be interviewed and/or have my picture or story used to help spread DCB’s mission.

______YES ______NO ______UNSURE, I have questions about this

MAIL THIS COMPLETED FORM TO:

Delta Cotton Belles – Service Request

P. O. Box 1292

Greenville, MS 38702

For additional information, please visit our website www.deltacottonbelles.org or call 662-390-6009

and leave a message. A volunteer will return your call.

Funds for these services are provided by our annual fundraising event and through a grant from The Kings’ Daughters and Sons Circle Number Two.