Delta Cotton Belles
FOR DCB RECORDS
Date service requested ______
Date service provided _______
Action taken ______________
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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: ________
Mailing 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 and/or lymphedema glove
_________ Wig
_________ Transportation assistance for medical visits or treatments (Double Quick gas cards)
_________ “Thrivers” Breast Cancer Support Programs
_________ 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 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.
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