Application: Step 1

Before you begin the application process, please take a moment to review our online application instructions below. As a nonprofit charity, Bent But Not Broken is dependent upon donations from corporations and individuals to carry out our mission. We are extremely grateful to our donors for making our program possible and for helping us provide hope and help to thousands of patients in need. It is our sincere desire to help as many patients as possible afford the medical treatments they need, but due to limited resources and high patient demand, we are not able to help everyone who applies. For patients that are on medications and would like assistance with those, most drug manufacturers (pharmaceutical companies) offer Patient Assistance Programs (PAPs) for insured patients who cannot afford their medications. In many cases these drug manufacturer PAPs offer MORE assistance than what Bent But Not Broken can offer. If you have not yet contacted the manufacturer of your medication to ask about possible assistance through them, we ask that you look into their assistance as well. We have links to various PAPs on our resources page.

Attention Providers & Advocates:
If you are applying on behalf of a patient, you will not be able to complete this application form without the patient’s permission. You will be required to attest that you have spoken with the patient and have received his or her permission to submit an application to Bent But Not Broken. You will have to provide your contact information as well as information for the applicant.

Attention Parents & Guardians:
If you are applying on behalf of a minor, please be advised that only people over the age of 18 may fill out an application. Those serving as parents, guardians or power of attorney to act on another’s behalf, will have to provide their contact information as well as information for the applicant.

Privacy: Bent But Not Broken recognizes how important privacy protection is, especially regarding your personal financial and health care information. We will keep your application for assistance confidential and not share any of your information with outside parties. We do not partner, share or sell any information gathered on this site including user statistics.

Application Step 2: Patient Attestation

In consideration for acceptance into Bent But Not Broken’s patient assistance program (Program), I agree and certify as follows:

All information I have provided, and will provide, to Bent But Not Broken in my application process and for assistance is and will be true and complete.

  • I will promptly notify Bent But Not Broken of any changes to the information I have provided to Bent But Not Broken.
  • I am free to change my physician, pharmacy, and medication at any time.
  • Bent But Not Broken can at any time audit my Program eligibility and the accuracy of any documents or information I provide.
  • If I don’t promptly provide all documentation and information requested by Bent But Not Broken, or Bent But Not Broken determines I do not meet Program eligibility or assistance requirements, my Program participation and all assistance may be immediately terminated.
  • I am not receiving financial assistance for the same expenses for which I have applied, or will apply, to Bent But Not Broken.
  • Bent But Not Broken will be in no way liable for the success or failure of any therapy or treatment I am taking.
  • Bent But Not Broken and its agents can obtain and discuss medical, treatment, therapy, financial and other information relating to my Program assistance with my providers, pharmacy, employer, insurance company, and any other person or organization working on my behalf to obtain eligible treatment or therapy.
  • Bent But Not Broken can at any time, and without notice, modify or discontinue all or any part of the Program and/or any assistance provided to me.

I will fully comply with such Terms and Conditions and all Program eligibility and other requirements, and if I fail to do so my Program participation and all assistance can be immediately terminated.

Application Step 3: Fill Out Application

Submit online: CLICK HERE to fill out and submit your application online
Submit via postal mail: CLICK HERE to download, print and then mail in your application