The BIA-ALCL Patient Assistance Fund - The Aesthetic Society 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the patient’s clinical history. Include the date of ALCL diagnosis, prior surgeries, and current status. Attach all relevant diagnostic reports.
3. Outline the surgical plan and goals for the patient in the designated section.
4. Specify the amount of funds requested, ensuring it does not exceed $6,500. Clearly state how these funds will be used.
5. Confirm that both patient and surgeon agree to report case details to required registries and share pathology specimens as needed.
6. Ensure you have an original signed copy of the ASERF Patient Photographic Authorization and Release ready for submission.
7. Finally, sign and date the application to certify that all information is accurate before mailing it to ASERF.

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