Period Product Support

Period Product Support
Feminine hygiene products, sanitary products, menstrual products, period products, whatever you call them, they're all the same--expensive! These products are a necessity, not a luxury, and they can put a strain on personal finances, causing many people to have to choose between purchasing products for their periods and purchasing food or other necessities. Having heavy or prolonged periods, as many women and girls with bleeding disorders do, increases the need for these products, creating an even greater impact on personal and family budgets. This fund will provide gift cards for period products.

Eligibility:
1. The applicant is a member of the Western Pennsylvania Bleeding Disorders Foundation with a diagnosed bleeding disorder.

2. The cost of period products is making it difficult to afford essential household bills.

3. If you have already received assistance from this program, and need further assistance, we encourage you to apply again. Applications will be reviewed on a case-by-case basis.

Application Process:
1. Submit your application by answering and submitting the following questions.

2. Confidential application call: A WPBDF staff member will review the application and contact the applicant to confirm information. Staff may also share additional resources that may help the household.

3. Efficient, effective help: When the application is approved, a gift card will be mailed or emailed to the applicant for immediate assistance.

If you have any questions or need assistance filling out this form, please call the Western Pennsylvania Bleeding Disorders Foundation at 724-741-6160.

Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

What bleeding disorder do you have?*
Please explain your need for assistance and any additional ways the Foundation can be of assistance.*
WPBDF patient assistance funds are intended to be used to help families manage financial stress due to a bleeding disorder; and therefore, our policy on distributing funds reflects this. We work closely with social workers from the Hemophilia Center of Western PA to ensure these funds are reaching patients in need, as a payer of last resort, and that patients are connected to other local resources and programs, as needed. This is one of the reasons why it is necessary to maintain regular clinic appointments: pediatric patients are typically seen 1-2 times a year, depending on their diagnosis, and adult patients are typically seen once a year or once every other year, depending on their diagnosis.

If you are not current on your clinic appointment and getting to the treatment center is a challenge for you, please know that funds are available to help you/your family members access care. Examples of transportation assistance include taxi fare, bus fare, and gas cards. For assistance with transportation costs, please contact a social worker at the HCWP (412-209-7280). During your appointment, HCWP staff can also help direct you to other specific resources that might benefit you.
Are you/your family member a patient of the Hemophilia Center of Western PA?*

YesNo

Hemophilia Center of Western PA
Enter the date of the last appointment at the Hemophilia Center of Western PA*

Other Medical Provider
Enter the name of your/your family member's medical provider that you see for bleeding disorder care.*
Enter the date of the last appointment with this provider for the bleeding disorder. *
Your provider may help manage some of the medical concerns that are causing financial strain.

Signature
Read the following statement and click the checkbox:*

I give WPBDF permission to verify my last hematology appointment date and, if needed, I agree to provide documentation of the last appointment date, upon request.
Read the following statement and click the checkbox:*

I declare that, to the best of my knowledge, the information provided is true; and I understand that any willful dishonesty may make me ineligible for future assistance.
By selecting the "I Agree" checkbox, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this application for assistance.*

I Agree.
Signature*

Clear
Should be Empty:

Period Product Support

Hemophilia Center of Western PA

Other Medical Provider

Signature