Emergency Financial Assistance - Bleeding Disorders Foundation of Florida

The Bleeding Disorders Foundation of Florida designed the Emergency Financial Assistance Program (EFAP) to help people with bleeding disorders. Hemophilia Foundation Emergency Financial Assistance Program funds are intended for a crisis situation or unforeseen emergency. All requests for assistance with rent, utilities, mortgage, medical bills and medical equipment must be in the name of the person with the bleeding disorder, unless the person with the bleeding disorder is under the age of 18. Therefore, the names of family members and other relatives are prohibited from financial assistance.

Emergency Financial Assistance Form

All fields marked with an asterisk are required. Make sure to attach supporting documents (see details on this page) when applying.

Name of Patient

Patient's D.O.B.

Patient's Marital Status

Name of Requester

Relationship to Patient

Address

Apt#

City

State

ZIP Code

Home Phone

Cell Phone

Work Phone

Employer

Occupation

Monthly Income
(include all members of household income)

$ Employment
$ Unemployment
$ Workers Comp
$ Pension
$ Child Support
$ Alimony
$ SSI
$ SSDI
$ Food Stamps
$ Section 8
$ Other Income (bonuses, etc.)
$ Other Income (government assistance, etc.)

Monthly Expenses
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$ Rent/Mortgage
$ Electric
$ Water/Sewer
$ Phone/Cell
$ Food
$ Car Payment
$ Car Insurance
$ Gas/Travel
$ Credit Cards
$ Cable/Internet
$ Childcare
$ Other Expenses

Explain the specific need in detail (attach any documentation below)
State why income is not available for this emergency
Diagnosis
Hemophilia Treatment Center (HTC)
Hematologist
Social Worker Referral & Contact Info.

Household Members
Press blue "add additional member" button to add another household member.

Household Member {{rep-1_index}}

Name

D.O.B

Relationship

Specify relationship

Documentation
Documents needed for every application: paycheck stubs (for every working person in household), bill (invoice) you need help paying, current lease agreement (for rental assistance), letter from your HTC (for dental assistance), treatment plan for services. Press blue "add additional document" button to add another household document.

Document {{rep-2_index}}

Documentation Type

File Description

File

Agreement and Consent
I certify that the information I have provided in the above is true and correct. I consent to the release of pertinent information contained in this application to the Bleeding Disorders Foundation of Florida, Inc., other social service agencies which distribute emergency financial assistance, the company or individual to receive 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 the recipients' funds. I acknowledge that I have read the Emergency Financial Assistance Guidelines above and will adhere to them.

Please check the box if you agree to the above statement, then type your initials into the box below.

I agree

Initials

Type red code into box

Guidelines

Before filling out the application, please keep the following mind:

The Bleeding Disorders Foundation of Florida Emergency Financial Assistance Program is for people with bleeding disorders and their families in emergency situations only - such as rent, some medical assistance, Utility Bills, Mortgages, Food, and Transportation for medical or chapter appointments. The BDFF does not assist with the following request:
- Appliances
- Auto Tags/licenses
- Auto Payments/Repairs/Rentals
- Auto Tires
- Credit Cards (debts or payments)
- Computers
- Cable TV/internet
- Cell Phones/Home Phones
- Clothes/shoes
- Dues
- House repairs/modifications/renovations
- Insurance Premiums/ Homeowners Insurance/Fees/Dues
- Legal Fees
Clients receiving treatment at an HTC must be referred to the BDFF by the HTC.
The person seeking assistance must submit the name(s) of person(s) living in the household affected with a Bleeding Disorder & state the Bleeding Disorder type before BDFF will review the financial request.
The form must be completed and a detailed written explanation of the reason needing financial assistance is required with the application. Failure to complete the forms will delay or terminate the financial assistance.
Household income and gross earnings must be disclosed such as:
- Most recent tax return
- Bank statement
- W-2
- A copy of your 2 most recent pay stubs
- A copy of all government assistance received (SSI, SSDI, Section 8, and food stamps)
Please include a copy of the bill or invoice that you are requesting for payment. All payments will be made directly to the service provider or creditor. payments will be paid directly to the applicant.
Financial assistance cannot exceed $500 per year (family) during a 12 month period.
Your request will be evaluated within 7 days of receipt of your completed application.
The Foundation reserves the right to refuse financial assistance. If a client’s request is denied, you have the right to appeal.

* The applicant requesting bill, mortgage/rent assistance must have their name on the bill/lease/statement.

Documents needed for every application

Copy of every working person in the households paycheck stub
Copy of the bill in which you are requesting assistance with paying
Any other documents that support your request

Additional documentation for dental assistance

Letter from your HTC
Treatment plan for services

Additional documentation for rental assistance

Current lease agreement