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Application

Application Instructions

Review Frequently Asked Questions to assure that you are eligible for assistance (over)
Fill out all forms completely, including required signatures. If something does not apply to you, indicate N/A
Before completing application, consult with a clinic/prosthetist for an initial evaluation. Clinic/prosthetist must complete and sign sections of the application as well
Incomplete Applications Will Delay the Approval Process

When completed:

Mail, email or fax application and copy of readable identification - current state-issued Driver’s License or Identification Card OR Permanent Resident Card, if not U.S. citizen to:

Women of Hope Foundation
P.O. Box 292705 ∙
Davie, FL ∙ 33329

www.womenofhopeintl.org
Fax 123-456-7890
info@womenofhopeintl.org

Upon receipt of completed application, Women of Hope Foundation will:
Review information
Conduct a criminal background check
Notify patients if they qualify for financial assistance

After a patient qualifies for assistance, patient is placed on a waiting list until funds are available. The waiting period may be 3-6 months from the time of qualification

When the funds become available:
Patient will receive a call to confirm that prosthetic work may begin at this time
Confirmation letters mailed to prosthetic salon and to patient
Women of Hope will not pay charges incurred before the confirmation letter has been issued, including being fitted or ordering hair
Women of Hope’s commitment will expire 1 year from the date of the confirmation letter


FREQUENTLY ASKED QUESTIONS

Am I eligible for assistance through Women of Hope?
Women of Hope (WOH) provides assistance for women who have lost their hair due to autoimmune disease i.e. Mixed Connective Tissue Disease, Lupus, Alopecia
Applicant must be a U.S. citizen or a permanent resident of the U.S
Applicant must have no other means to pay for prosthetic care including Medicare, insurance coverage or state assistance
Applicant must work with agreed prosthetist provider

How do I apply for assistance?
Complete the application and have your prosthetist or clinic complete their sections as well
Include a readable copy of your photo ID (If not a US citizen, you must send a copy of your Permanent Resident Card
Send application and photo ID to Women of Hope Foundation by mail, email or fax

How long will it take to get my new hair?
Once your complete application is received, background check and review can take 3 days to two weeks
Applicants with felonies will be reviewed by an advisory committee which meets every 4-6 weeks Once approved, you will be moved to the Waiting List until funds are available. This may take as long as six (6) months

What if I gain other coverage for my prosthetic care prior to receiving confirmation from WOH?
Notify the WOH office as soon as possible so that the funds can be used to help another woman who has lost her hair due to illness and cannot afford prosthesis.

I have other questions.
Call the Women of Hope office between 9:00 a.m. and 5:00 p.m., Eastern Time at 1-234-567-8900 or email info@womenofhope.org.
WOH staff is here to answer your questions! 

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