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  • Financial Assistance Application

    Please fill out all sections below to apply for Financial Assistance from the Nevada Chapter of the National Bleeding Disorders Foundation (NV-NBDF).  Please remember that financial assistance depends on the availability of funds and applicant eligibility.  Funding is not guaranteed.  Applicants should allow at least 10 business days for the (NV-NBDF) to process a request. Qualified applicants will be added to the NV-NBDF database.

  • Financial Assistance Eligibility Guidelines

    Prospective applicants will need to meet the following criteria:
     

    • Be a resident of Nevada
    • Be an individual with a bleeding disorder diagnosis OR
    • Be a parent or caregiver of a minor child who lives in your home and who has a diagnosis of a bleeding disorder
    • Must be a patient and receive treatment from the Hemostasis & Thrombosis Center of Nevada (HTC-NV) .
    • Must have completed a Comprehensive Care clinic visit within 12 months of this request.
    • Fully complete this Financial Assistance application
    • Must meet all eligibility requirements determined by the Nevada Chapter of the National Bleeding Disorders Foundation (NV-NBDF).
    • Have not previously applied and been approved for financial assistance from NV-NBDF in this calendar year.

  • Basic Information

    Applications with missing information will not be accepted. If you need assistance in completing your application, please contact Jacob Murdock at jmurdock@bleeding.org, or 646-901-6442.
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  • Applicant Contact Information

  • Household Information

  • Emergency Financial Assistance Request

    Please use as MUCH DETAIL as possible to describe your request. Applications without significant detail will be sent back for follow up.

  • Bill Payment Priority Request Information

    NV-NBDF cannot provide funding directly to individuals, but if approved, NV-NBDF will pay a vendor directly with assistance from the applicant.  Please list your bill payment information below and download any copies of the specific payment stub, bill, or notice.
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  • Application Request Confirmation

    Applicants and information pertaining to funding requests are considered confidential to the full extent permitted by law. All NV Chapter Advisory Board/Financial Assistance Committee members are required to sign a confidentiality agreement. Information from the NV-NBDF Financial Assistance applications may be compiled for statistical purposes and for compliance with local, state, federal or affiliate organization requirements.  However, any publication of this data will be in aggregate form only and will not include names or any other information that could be used to identify individual applicants or recipients. No personal information will be used or disclosed for any purposes other than that for which it was collected without applicants' written permission.  At no time will personal information be shared with any individual, company, and organization outside the NV-NBDF.

  • After you have fully completed your application, please select the green submit button below. 

    • An automatic response email from JOTFORM will be sent to the applicant's email. Please check the spam/junk folder to ensure your application has been submitted.
    • Please allow at least 3 business days for your application to be processed for eligibility.
    • Additional Communication may come from:

     

    Chloe Gardner, cgardner@bleeding.org, (702) 306-5513

    • If you have any questions or concerns, please do not hesitate to reach out to us. We will reach out to you to confirm eligibility and notify you of the status of your application request. 

     

     

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