Application

Applications for assistance are completed by downloading the two-part application. 
The first part is to be filled out by the applicant themselves and the second part is to completed by the applicant’s medical care provider.

To Qualify, a recipient must be:

• Uninsured or underserved
• Diagnosed by a medical professional as having breast cancer
• In financial need.

Upon completion, the Luminous Breast Cancer Foundation’s Case Manager will review and pending approval the applicant will be contacted as soon as possible.  Resources are limited and based on availability.

Download the Application to your Computer:
Patient Application (PDF)
Medical Application (PDF)

Mail to:

Luminous Breast Cancer Foundation
Attn: Case Manager
400 Cameron Station Blvd. Suite 418
Alexandria, VA  22304

Fax to:

(703) 842-8488

Email to:

alexandra.boos@luminousfoundation.org

All information is held in strict confidence and is for the Luminous Breast Cancer Foundation only.  Please call (571) 970-3303 with any questions.

Read our privacy policy here.