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The Breast Cancer Reconstructive Surgery Fund

Through a generous grant from an anonymous donor, administered by the Cape Cod Foundation, Cape Cod Healthcare provides financial assistance to women facing breast reconstruction surgery.

This year, the Breast Cancer Reconstructive Surgery Fund totals $50,000, which will be administered by the Cape Cod Foundation and has been awarded to Cape Cod Healthcare. The grant will be replenished each calendar year through the distribution of the initial $1.5 million anonymous endowment.

The Breast Cancer Reconstruction Surgery Fund is available to women who live in Barnstable County, to help with the costs of breast reconstruction not covered by insurance. It is also open to Barnstable County patients with hereditary cancer syndromes who have not had a cancer diagnosis, for use covering a prophylactic mastectomy, as well as for breast reconstruction patients whose insurance is not accepted by their plastic surgeon. The funds are available on a first-come, first-served basis.

The Breast Cancer Reconstructive Surgery Fund of The Cape Cod Foundation covers costs of unpaid bills that fall outside of insurance coverage, including, without limitation, deductibles, co-payments and/or all surgical costs for women who have had all or any part of either or both breasts removed due to a cancer diagnosis.

The funds are available through Cape Cod Healthcare, via application below, to any woman residing in Barnstable County undergoing breast reconstruction related to a breast cancer diagnosis.

For questions about the Breast Cancer Reconstructive Surgery Fund of The Cape Cod Foundation, please contact Barbara Archambeault, RTT, MHA, Oncology Operations Manager, Davenport-Mugar Cancer Center at barbarchambeault@capecodhealth.org.

Instructions:

Patient should complete Sections 1, 2, 3, and 4 of this form in their entirety. Please remember to sign and date the form.

Answer to the best of your ability, even if the answer is 'I don't know' or 'Not Applicable'. Then click the 'Submit' button to submit your application.

* Denotes required fields

Section 1: Personal Data

* First Name

M.I.

* Last Name

* Address

* City

* State Example: NY

* ZIP Code Example: 12345

* Last 4-digits of Social Security Number

* Date of Birth mm/dd/yyyy

* Home Phone Example: 123-123-1234 x123

* Work Phone Example: 123-123-1234 x123

* Email

* Gender

Female
Male

* Marital Status

Married
Single

Section 2: Insurance

* Insurance Carrier

* Policy ID#

* Employer

* Subscriber

* Subscriber ID#

* Subscriber Date of Birth mm/dd/yyyy

Section 3: Medical History

* Date of diagnosis mm/dd/yyyy

* Diagnosis

* Date of mastectomy mm/dd/yyyy

* Planned date of reconstruction mm/dd/yyyy

* Who performed mastectomy

* Was mastectomy single or both breasts? If single, which breast?

* At what facility will reconstruction be performed?

* Who will perform reconstruction

Section 4: Assistance Requested

* Amount Requested

* Service Performed for Amount Requested

By checking this box I acknowledge the information above and equate this as my digital signature.

* Signature of Applicant

* Today's Date mm/dd/yyyy

As a non-profit, community healthcare system, Cape Cod Healthcare’s mission is to provide quality healthcare to all members of the Cape Cod community, no matter their ability to pay.

The goal of the Breast Cancer Reconstructive Surgery Fund is to cover any costs associated with reconstructive surgery not covered by health insurance for women residing in Barnstable County who have had all or any part of either or both breasts removed due to a cancer diagnosis. The fund can cover costs including, but not limited to deductibles, co-pays and/or all surgical costs not covered by insurance. Please be prepared to provide supporting documentation for all information listed in this document.