Information collected in this application will be used by our approval committee to process your medical travel reimbursement request. All data provided will be kept in strict confidence and only used for this purpose. 

If approved, the applicant will receive a reimbursement up to $2,000 for travel expenses. The funds will only be distributed AFTER the medical procedure and travel have been completed, and receipts for all travel reimbursement requests have been submitted to the Moebius Syndrome Foundation within 30 days following the medical appointment.

Before completing the application, please review the requirements below to make sure you qualify for the program.

• Applicant/Patient must be a resident of the United States - including Puerto Rico and all US territories.
• Patient must have Moebius syndrome
• Patient must have a confirmed medical appointment scheduled in the United States a minimum of 30 days from the application date. 
• The medical appointment must be a result of a condition or symptoms caused by having Moebius syndrome.
• Patient must be medically cleared to safely travel. 
• Applicant must be 18 years of age or older, or have a parent/legal guardian complete the application. 

If you meet all of these requirements, please proceed with the application.

The following information may be used in reporting demographic statistics to various foundations and government agencies that offer grant funding to organizations like the MSF, and require this information to verify the impact and scope of our programs. It will not be used to determine who is eligible to receive the medical travel funds.

In the case where a child (infant to 17 years old) is the patient - the education, marital status, and employment questions apply to the parent/legal guardian completing this application.

Meal Per Diem

Meals are reimbursed up to the daily GSA per diem rate for the city where medical care is received, based on current-year rates published at GSA.gov. This limit applies per person, per day.

Non-Reimbursable Items

The Moebius Syndrome Foundation does not reimburse for alcohol, tobacco, luxury items, or personal entertainment. If a receipt includes any of these items, the cost of the item(s) and its associated tax will be deducted from the reimbursement amount.

Gratuity

Gratuity (tipping) is reimbursable up to a maximum of 20% (before tax) per receipt. Anything over this amount will be deducted from the reimbursement amount.

Receipt Submission

Receipts should be scanned individually and clearly for digital submission and emailed to info@moebiussyndrome.org, along with a completed sheet that matches the receipts to travel dates (the MSF will send this sheet to approved applicants in advance of their trip). If scanning isn't possible, physical copies may be mailed instead to Moebius Syndrome Foundation, 1312 17th Street, PMB 976, Denver, CO 80202.

Waiver of Liability

In consideration of their providing financial assistance for reimbursement, I, the undersigned, do hereby release the nonprofit, Moebius Syndrome Foundation, fully and without reservation from any and all claims whatsoever of culpability, responsibility, fault and liability for any inadvertent and/or accidental occurrence which may result in personal injury or property damage or other effects, during all times that I am a passenger or patient in the act of traveling or being treated.

Waive Right to Pursue Legal Action

Furthermore, I do here with unequivocally waive and deny, for myself and all patients and passengers, any and all rights to pursue any action against the Moebius Syndrome Foundation for any action or inaction executed by them in good faith.

Application Changes

I will email the Moebius Syndrome Foundation at info@moebiussyndrome.org with any amendments or changes needed to my original application if needed. I acknowledge that the Moebius Syndrome Foundation is the only party that can cancel or amend my reimbursement.