Emergency Financial Assistance Request

Recommendation for Emergency Financial Assistance

This form must be filled out and submitted by an HTC staff member or treating hematologist.
The purpose of the Emergency Assistance Fund is to provide last resort assistance to persons with bleeding disorders for emergency expenses that arise because of complications directly related to their bleeding disorder.

The maximum emergency assistance payment per family is $500 per calendar year. Occasionally, when extenuating circumstances arise, the committee may approve requests up to $1,500. That will, however, affect future requests. For example, if you receive $1,000 in one calendar year, you will be ineligible to apply the following year. If you receive $1,500, you will be ineligible to apply for the following two years. There is a $2,000 lifetime household cap. Only certain qualified expenses will be considered. GOBDF will not reimburse for funds not approved ahead of time. Submissions must be reviewed prior to approval, which can take up to one week. All submissions must be submitted via your HTC social worker.

Resources are limited and priority will be given to families with young children with bleeding disorders.

Applicants who are affiliated with an HTC must be referred by their HTC Social Worker and be compliant with their medical treatment. The eligibility criteria for the emergency assistance funds are as follows:

-Applications for the funds are limited to current members of the GOBDF;

-All requests for assistance must be referred through the HTC; families not affiliated with an HTC may apply directly to the GOBDF, with a referral from their healthcare provider;

-There must be at least one person with a bleeding disorder living in the household;

-All payments for approved emergency assistance must be made to a qualified third party, such as a landlord, vendor, utility company, etc.

-The applicant is required to provide documentation of the need and complete a standard application form;

The GOBDF realizes that all families with bleeding disorders have financial burdens. However, the purpose of the Financial Assistance Fund is to help people with one-time, extraordinary expenses. Unfortunately, the GOBDF does not have the resources to help with usual and customary living expenses. We regret that not all families can receive assistance.
Name of Referring Staff Member*
Referring HTC*
If you answered "other" above, please explain your role.
Patient Name*
Patient Diagnosis*
Other Patient Diagnosis: (please note that our chapter serves patients and families with factor deficient bleeding disorders. Other disorders, such as thrombophilia, platelet dysfunction, etc. may be supported when funds are available at the recommendation by the HTC).
Patient Mailing Address. They may opt out at any time.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Email*
Patient Phone Number*
Format: (000) 000-0000.
County*
Amount Requested*
Date funds needed*
Other Sources and dates of Assistance Sought. *
Nature of the Request/Extenuating Circumstances AND how this assistance will resolve the current need. *
Yes, within the past 12 monthsYes, but not within the past 12 monthsNoUnsure
Please upload bill(s) for which you are requesting assistance*

Cancelof
If information is not visible on attached bill, please include the company, account number, phone number and website when available
Please verify that you are human*
I certify that the information I have submitted is true and accurate to the best of my knowledge

Clear
Should be Empty:

Recommendation for Emergency Financial Assistance