Hemophilia Foundation of Maryland Patient Assistance Fund
HFM is dedicated to improving the quality of life for persons with bleeding disorders.
Name of Applicant:
*
First Name
Last Name
Applicant's Date of Birth:
*
-
Month
-
Day
Year
Date
Applicant's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
*
example@example.com
Number of Adults (18 & over) Residing in your Household:
*
Number of Children (under age 18) Residing in your Household:
*
Information on each individual in your family (include those with and without a bleeding disorder diagnosis:
*
Rows
Name
Birthdate
Diagnosis & Severity
Relationship to Applicant
Household Member 1
Household Member 2
Household Member 3
Household Member 4
Household Member 5
Household Member 6
Household Member 7
Household Member 8
Household Member 9
Household Member 10
Name of the Hemophilia Treatment Center the Bleeding Disorder Patient receives Treatment:
*
Please Select
Johns Hopkins Hemophilia Treatment Center
Georgetown
Children's National Medical Center
Other
If you selected "Other" above, please provide the name and telephone number of the bleeding disorder patient's treating hematologist:
Name of the Bleeding Disorder Patient's Specialty Pharmacy:
Please explain your financial situation:
*
Name of the Creditor you are Requesting Assistance in Paying:
*
Amount of Assistance you are Requesting:
*
Have your requested funds from another group for this same request
*
Yes
No
If yes, please specify which organization(s), the amount of funds requested, and the date(s) funds were requested.
Rows
Organization Name
Amount of Funds Requested
Date Funds were Requested
If you received funds from this organization, please state how much you received.
1.
2.
3.
4.
Please upload a copy of the bill you are requesting assistance with? Please ensure the billing statement includes the creditor's name, creditor's address, account number and amount owed.
*
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Please upload your last two paystubs for all adults residing in the household. If any household member receives SSI or SSDI, please attached a copy of your SSI or SSDI determination letter
*
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Certification - I am an individual with a congenital bleeding disorder or a parent of a person with a bleeding disorder in need of financial assistance. I certify that the information included on this application is true and complete. I authorize the release of information to the Hemophilia Foundation of Maryland in order to verify all statements made in this application. I also give permission to contact a representative at my local hemophilia treatment center as necessary.
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