VHF Financial Assistance Program Request For Services Form

VHF Financial Assistance Program Request For Services Form

NOTE: Successful applicants will coordinate requests, with a social worker and/or nurse coordinator at a hemophilia treatment center or other healthcare provider treating bleeding disorders, which includes having them review your application and forwarding the application and/or submitting a referral to info@vahemophilia.org. For questions info@vahemophilia.org or (804) 740-8643.
Individual Requesting Assistance - Contact Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you over the age of 18?*

YesNo
If under 18, List the Name of your Parent/Guardian*

First NameLast Name
If under 18, List the Cell Phone Number of your Parent/Guardian*
Please enter a valid phone number.
If under 18, List the Email of your Parent/Guardian*
example@example.com
How did you hear about VHF's Financial Assistance Program?*

Internet SearchSocial MediaFriend/Family MemberHealthcare ProviderVHF email and/or at an eventOther
If you answered health care provider, please provide their name and contact information:*
If you answered other, please explain:*
Have you or a family member ever received financial assistance from VHF?*

YesNoI do not know
If you answered yes, when was assistance received?*
Do you have an inherited bleeding disorder?*

YesNo
If you answered no, what is your relationship to the person in your household with an inherited bleeding disorder?*

Parent and/or GuardianCaregiverSpouseOther
What type of inherited bleeding disorder do you (or your family/household member) have?*

Hemophilia AHemophilia Bvon Willebrand disease (VWD)Platelet DisorderRare Factor DeficiencyOther
If you answered other, please explain:*
Where does the person with an inherited bleeding disorder receive treatment for their bleeding disorder? *
What type of insurance do you have?*

PrivateMedicareMedicaidTricareOther
If you answered other, please explain:*
Monthly Income: $*
Monthly Expenses: $*
Number of Adults (18+) in the Household?*
Number of Children (under 18) in the Household?*
Amount Requested: $*
Up to $500
What is the purpose of the requested amount?*

Emergency AssistanceBasic Needs (Food, Shelter, Clothing)Medical ExpensesUtility BillsRent/Housing SupportEducational ExpensesOther
If you answered other, please explain:*
Is this expense a one-time expense or monthly?*

One-timeMonthly
If monthly, what are you doing to ensure that this bill will be paid next month? *
What other organizations have you applied to for assistance?*
Upload Supporting Documents

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Additional Comments/Notes
This request will be forwarded to the Virginia Hemophilia Foundation (VHF) Scholarship Committee. Identifying information will not be shared with the committee. Additional information may be required. All payments will be made directly to the party that is owed the monies.
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VHF Financial Assistance Program Request For Services Form

Individual Requesting Assistance - Contact Information