***All sections must be filled out and supporting documents must be attached prior to processing***
***The processing of this application can take 2 to 3 days to complete***
Release of Infirmation/Applicant Attestion: I certify that the information I have provided is true and correct. I consent to the release of pertinent information contained in this application the Tennessee Hemophilia & Bleeding Disorders Foundation, other social service agencies which distribute emergency financial assistance, the company or individual to treceive funds as necessary to complete the services to my household, or to provide statistics on emergency assistance, or as a guard against duplicate assistance. I also consent to release of patient information to the federal government and those utility companies which require documentation of receipient's funds.