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. 
• 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 is needed to proceed with the application:

• Scheduled Medical Appointment and Release Date(s) -- Your treatment site must be able to verify your medical appointment date(s)
• Requested Travel Dates (within 2 days of medical appointment)
• Medical Provider's contact information
• Verification from the medical provider's office (A separate form will be emailed to you to have them complete once this application is submitted.)

Please make sure you have the above information ready BEFORE moving forward with your application. Total time to complete the application is less than 15 minutes.

If you have questions about the application, please contact us at info@moebiussyndrome.org.

The following information will be used in reporting demographic statistics to various foundations and government agencies. 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.

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 call the Moebius Syndrome Foundation at (844) 663-2487 ext. 703 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.