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Patient assistance bia alcl 2026

The BIA-ALCL Patient Assistance Fund, established by the American Society for Aesthetic Plastic Surgery and other organizations, provides financial support for underinsured or uninsured patients diagnosed with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The fund covers surgical treatments such as total capsulectomy and explantation, along with associated costs. Eligibility criteria include lack of health insurance, residency in the U.S., and a confirmed diagnosis of ALCL. The document outlines patient and surgeon requirements, fund usage, exclusions, and the application process.

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Click ‘Get Form’ to open the patient assistance bia alcl application in the editor.
Begin by filling out the patient's personal information, including their name, address, and contact details. Ensure accuracy as this information is crucial for processing.
Provide a brief clinical history of the patient. Include the date of ALCL diagnosis, prior surgeries, and current status. Attach copies of all relevant diagnostic reports.
Outline the surgical plan and goals for the patient clearly. This section should detail what procedures are being requested and why they are necessary.
Indicate the amount of funds requested, ensuring it does not exceed $6,500. Specify how these funds will be used in relation to the treatment.
Complete any required acknowledgments regarding reporting case details to registries and sharing pathology specimens as outlined in the guidelines.
Finally, review all entries for completeness and accuracy before submitting your application via mail as instructed.

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Versions	Form popularity	Fillable & printable
2019	4.5 Satisfied (23 Votes)
2018	4.3 Satisfied (46 Votes)

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