For Providers

Dear Provider:

Thank you for choosing HERS Breast Cancer Foundation Program Stores for your patient’s post-surgical needs. To assist us in providing the best care for your patient, we require a prescription or insurance authorization.

Please fill out the appropriate form below and return this to us via fax. If you have any questions please feel free to contact us at the Fremont location.

Be well,
HERS Breast Cancer Foundation, Program Stores

Downloadable Forms:

• Rx Request Form  – for patients with PPO and Medicare insurance plans
• Authorization Request Form – for patients with HMO insurance plans