Financial Assistance Application

Financial Assistance Application

Please fill out all sections below to apply for Emergency Financial Assistance from the Nevada Chapter of NHF.  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 Nevada Chapter of NHF to process your request.

Completion of this application will automatically register you with the Nevada Chapter of NHF and place you on the mailing list.

 

I have read and understand the Emergency Financial Assistance Program Guidelines & Policy
BASIC INFORMATION
Do You Have Medicaid?
Is Spouse Employed?
The Applicant is
Is the Person/Child with a Bleeding Disorder a Patient of a Hemostasis and Thrombosis Center of Nevada
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.
Nevada NHF is able to provide a maximum of $500 of funding per person/family per year.
Please be aware that Nevada Chapter of NHF may need up to two weeks to process a request.
Have you applied for Financial Assistance from the Nevada Chapter of NHF in the past?

Nevada Chapter of NHF cannot provide funding directly to individuals, but if approved, Nevada Chapter of NHF will pay a vendor directly.  Please list your bill payment information below and email copies of bills with contact information to bvandeusen@hemophilia.org.  

 

 

BILL PAYMENT REQUEST INFORMATION
I certify that the information I have submitted is true and accurate to the best of my knowledge. In the event there is a monthly income increase or decrease of more than 10% as reported on this application, I will notify the Nevada Chapter of NHF within 30 days.

CONFIDENTIALITY

Applicants and information pertaining to funding requests are considered confidential to the full extent permitted by law. All Nevada Chapter of NHF Advisory Board/Emergency Assistance Committee members are required to sign a confidentiality agreement. 

Information from the Nevada Chapter of NHF's Emergency 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 Nevada Chapter of the National Hemophilia Foundation.