Application for Counseling Assistance
Who is eligible to apply?
Any member with an eligible diagnosed bleeding disorder or their caregiver living in the same home is eligible to apply for $400 per calendar year. Those with special circumstances are encouraged to apply for additional funds if needed. This benefit is intended to cover the cost of deductibles and other out-of-pocket expenses that are not covered by insurance for counseling. I understand that my submission of this application does not guarantee that I will receive assistance.
Checks will be written out directly to the provider.
We will not reimburse for expenses paid.
Date
*
-
Month
-
Day
Year
Date
First Name
*
Last Name
*
Age
*
Type of Bleeding Disorder
*
Which Hemophilia Treatment Center are you seen at?
Please Select
Akron Children's
Nationwide Children's
The Ohio State University
University Hospitals
Other
I give my HTC or treating hospital permission to confirm my/my family members' bleeding disorder diagnosis with chapter staff.
Yes (Required to attend programs and receive services)
No
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Please Select
Athens
Belmont
Delaware
Fairfield
Fayette
Franklin
Gallia
Guernsey
Hocking
Jackson
Lawrence
Licking
Madison
Marion
Meigs
Monroe
Morrow
Morgan
Muskingum
Noble
Perry
Pickaway
Pike
Ross
Scioto
Union
Vinton
Washington
OTHER
Email Address
*
Name of Counselor/Mental Health Provider
*
Office phone number of Counselor/Mental Health Provider
*
Address of Counselor/Mental Health Provider (please ensure that this is the correct address for receiving payments)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current bill from practice (Please attach)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Notes/Comments/Special Requests
Signature of Applicant
Please verify that you are human
*
Submit
Should be Empty: