Helping Hands, including email referrals, will remain on a prolonged pause to afford HFA an opportunity to secure additional funding sources and strengthen the Helping Hands programs. Visit our Resources for other assistance.

Our Helping Forward program, which offers Job Readiness Grants, remains open.

Block Question

Intro Text

HFA’s Helping Hands Program provides a critical safety net for families facing financial hardship. The program provides financial support to families in the bleeding disorders community in their time of need through the following programs:

Emergency Assistance: supports families experiencing hardship with urgent funding for basic living expenses such as housing, car payments, utility bills, or funeral assistance
Items Assistance: assists with the cost of durable medical equipment and other medically recommended items
Inhibitor Support: supports families affected by inhibitors with the cost of medical transportation and tutoring/educational supplies
Disaster Relief: provides community members who are displaced or impacted by a natural disaster with immediate financial relief

Visit the website for eligibility requirements details: http://www.hemophiliafed.org/helpinghands

Please contact HFA at helpinghands@hemophiliafed.org with questions.

Some text about Healthy Living

Which Assistance program are you applying for:

Emergency AssistanceHealthy LivingInhibitor SupportDisaster ReliefCOVID-19 Relief

Screening Questions

Is the household income significantly decreased because of the COVID-19 public health crisis?

YesNo

Do not proceed. The Relief Fund is for households experiencing a significant loss of income due to the COVID-19 pandemic. Please see HFA’s Helping Hands programs or our Patient Assistance Portal if the household is experiencing financial need unrelated to the impacts of COVID-19.

Is the family unable to pay one or more essential household bills because the COVID-19 pandemic has decreased household financial resources?

YesNo

Do not proceed. The Relief Fund is for households who have lost income because of the COVID-19 pandemic, urgently need assistance paying a household bill, and are unable to do so without HFA assistance.

Please see HFA’s Helping Hands programs or our Patient Assistance Portal to find a better fit for the household's needs.

Brief summary of how COVID-19 has impacted the family

Local Support

Many local bleeding disorder organizations have funding to assist community members with unexpected costs associated with having a bleeding disorder and financial, emergency, and disaster assistance and items.

"I have checked other alternative sources including my local bleeding disorder organization and HTC prior to applying for HFA’s Helping Hands program."

YesNo

Please contact the local bleeding disorder organization and treatment center about assistance prior to submitting an application to HFA's Helping Hands program.

Name of organization contacted:

Please list the name of the representative you spoke with:

Did the organization provide assistance?

YesNoRequest Pending

Notes about assistance requested / provided by the organization:

Referrer Information

Are you applying for yourself or on behalf of someone?

Applying for myselfApplying for a family memberApplying for a patient or client

Your First Name:

Your Last Name:

Your Phone:

Your Email:

Your Organization Name:

Type of Organization:

Your Position:

Your Title:

We do not accept self-referrals for Emergency Assistance. The referral must be submitted by an Eligible Referrer:

Physician, nurse, or social worker from a Hemophilia Treatment Center

Private physician

Representative from a national, regional, state, or local bleeding disorder organization

Homecare representative of the applicant

Not a relative or employer of the applicant

Primary Applicant Contact Information (Must be an ADULT)

Household (Last) Name:

Household Size (Adults and Children):

First Name:

Last Name:

Applicant's Street Address:

Address Line 2:

City:

State:

Zip Code:

Applicant's Primary Phone

Secondary Phone:

Applicant's Email Address:

Preferred language spoken:

EnglishSpanishOther

Please indicate translation needs. Can the referring organization or a household member translate for the applicant? Does HFA need to translate?

EmailNotification

Primary Applicant Information

First Name:

Last Name:

Marital Status:

Gender:

Birth Date:

Primary Applicant's Relationship to Person with Bleeding Disorder (check all that apply):

Adult w/ DisorderChild w/ DisorderCarrierPartner / Spouse of Someone w/ DisorderParent of Someone w/ DisorderChild of a Parent w/ DisorderSibling of Someone w/ DisorderGrandparent of Someone w/ DisorderOther Family of Someone w/ DisorderFriend of Someone w/ Disorder

Primary Applicant's Bleeding Disorder

Bleeding Disorder Type:

Bleeding Disorder Severity:

Complications:

Inhibitor	Hepatitis C
HIV	Joint Damage
Depression	Diabetes
Heart Disease	Liver Cancer
Other

Does the primary applicant receive care or services for your bleeding disorder at a hemophilia treatment center (HTC)?

YesNo

Hemophilia Treatment Center (HTC) Name (optional):

Hemotologist or Doctor Name (optional):

Additional Household Member's Information

Family Member #2

First Name:

Last Name:

Marital Status:

Gender:

Birth Date:

Relationship to Person with Bleeding Disorder:

Bleeding Disorder

Bleeding Disorder Type:

Bleeding Disorder Severity:

Complications:

Inhibitor	Hepatitis C
HIV	Joint Damage
Depression	Diabetes
Heart Disease	Liver Cancer
Other

Does the individual receive care or services for their bleeding disorder at a hemophilia treatment center (HTC)?

YesNo

Hemophilia Treatment Center (HTC) Name (optional):

Hemotologist or Doctor Name (optional):

Family Member #3

First Name:

Last Name:

Marital Status:

Gender:

Birth Date:

Relationship to Person with Bleeding Disorder:

Bleeding Disorder

Bleeding Disorder Type:

Bleeding Disorder Severity:

Complications:

Inhibitor	Hepatitis C
HIV	Joint Damage
Depression	Diabetes
Heart Disease	Liver Cancer
Other

Does the individual receive care or services for their bleeding disorder at a hemophilia treatment center (HTC)?

YesNo

Hemophilia Treatment Center (HTC) Name (optional):

Hemotologist or Doctor Name (optional):

Family Member #4

First Name:

Last Name:

Marital Status:

Gender:

Birth Date:

Relationship to Person with Bleeding Disorder:

Bleeding Disorder

Bleeding Disorder Type:

Bleeding Disorder Severity:

Complications:

Inhibitor	Hepatitis C
HIV	Joint Damage
Depression	Diabetes
Heart Disease	Liver Cancer
Other

Does the individual receive care or services for their bleeding disorder at a hemophilia treatment center (HTC)?

YesNo

Hemophilia Treatment Center (HTC) Name (optional):

Hemotologist or Doctor Name (optional):

Family Member #5

First Name:

Last Name:

Marital Status:

Gender:

Birth Date:

Relationship to Person with Bleeding Disorder:

Bleeding Disorder

Bleeding Disorder Type:

Bleeding Disorder Severity:

Complications:

Inhibitor	Hepatitis C
HIV	Joint Damage
Depression	Diabetes
Heart Disease	Liver Cancer
Other

Does the individual receive care or services for their bleeding disorder at a hemophilia treatment center (HTC)?

YesNo

Hemophilia Treatment Center (HTC) Name (optional):

Hemotologist or Doctor Name (optional):

Family Member #6

First Name:

Last Name:

Marital Status:

Gender:

Birth Date:

Relationship to Person with Bleeding Disorder:

Bleeding Disorder

Bleeding Disorder Type:

Bleeding Disorder Severity:

Complications:

Inhibitor	Hepatitis C
HIV	Joint Damage
Depression	Diabetes
Heart Disease	Liver Cancer
Other

Does the individual receive care or services for their bleeding disorder at a hemophilia treatment center (HTC)?

YesNo

Hemophilia Treatment Center (HTC) Name (optional):

Hemotologist or Doctor Name (optional):

Family Member #7

First Name:

Last Name:

Marital Status:

Gender:

Birth Date:

Relationship to Person with Bleeding Disorder:

Bleeding Disorder

Bleeding Disorder Type:

Bleeding Disorder Severity:

Complications:

Inhibitor	Hepatitis C
HIV	Joint Damage
Depression	Diabetes
Heart Disease	Liver Cancer
Other

Does the individual receive care or services for their bleeding disorder at a hemophilia treatment center (HTC)?

YesNo

Hemophilia Treatment Center (HTC) Name (optional):

Hemotologist or Doctor Name (optional):

Family Member #8

First Name:

Last Name:

Marital Status:

Gender:

Birth Date:

Relationship to Person with Bleeding Disorder:

Bleeding Disorder

Bleeding Disorder Type:

Bleeding Disorder Severity:

Complications:

Inhibitor	Hepatitis C
HIV	Joint Damage
Depression	Diabetes
Heart Disease	Liver Cancer
Other

Does the individual receive care or services for their bleeding disorder at a hemophilia treatment center (HTC)?

YesNo

Hemophilia Treatment Center (HTC) Name (optional):

Hemotologist or Doctor Name (optional):

Additional Family Members

Please list the names of any additional family members:

Assistance Request

Note: HFA cannot cover any medical expenses including medical bills, dental bills, insurance premiums, co-payments, deductibles, medications, factor, etc. We do not cover legal bills or provide grocery or gas cards.

Note: Our Disaster Relief Fund assists with needs such as temporary housing, replacement of necessary home items, household bills, and necessities like food and clothing. The amount and method of funding will be determined based on the applicant's need and disaster situation. Please summarize the needs below and we will be in touch with you soon.

What type of assistance is requested? (Choose one)

Housing (rent, mortgage)Transportation (car payment, repairs)Utilities (power, water, phone)Other

Other - Please Describe:

Please explain the Applicant's needs and requested assistance:

Total Amount of Assistance Requested:

If you have a copy of the bill, please upload it now. (PDF, JPG, PNG, GIF Files only)

What type of item are you requesting assistance for? (Choose one)

Brace or OrthoticMobility SupportProtective GearMedical identification jewelryIce or heat itemRefrigerationOther

Other - Please Describe:

*** All medical identification jewelry products must be purchased directly by the applicant. HFA is unable to purchase these items on your behalf. Please purchase directly from your preferred medical ID product provider. Once the item has been purchased, you must submit receipt of item along with medical documentation of proof of bleeding disorder in order to be eligible for reimbursement. HFA can reimburse applicants up to $45 plus shippping for ID jewelry. We do not reimburse for alert services unless specifically recommended by a medical provider.

Please describe the item(s) needed. The expedite requests, please include specific information on requested brands, sizing, links to the item(s), or other requirements.

Please explain the Applicant's need for the requested assistance:

Total Amount of Assistance Requested:

I understand that I must provide:

1) documentation from a healthcare provider confirming diagnosed bleeding disorder and recommendation for this request

AND

2) a receipt, invoice, or detailed instructions for ordering the exact item needed.

I understand that if I do not upload or email files to helpinghands@hemophiliafed.org now, there may be delays in processing this request.

Medical Verification

You may utilize this form or your own documentation. [CLICK HERE FOR FORM]

Please upload the medical verification / recommendation:

Please upload the invoice, receipt, order form, or item description (PDF, JPG, PNG, GIF Files only)

You may submit the required documents by email: helpinghands@hemophiliafed.org

What type of support are you requesting assistance with? (Choose one)

Medical TravelTutoring / Educational SuppliesOther

Other - Please Describe:

Please describe the support needed. To expedite requests, please include specific applicable information. (e.g. dates of medical travel, dates, and location, links to specific educational supplies needed, etc.)

Please explain the Applicant's need for the requested assistance:

Total Amount of Assistance Requested:

I understand that I must provide:

1) documentation from a healthcare provider confirming diagnosed inhibitor

AND

2) a receipt, invoice, or detailed instructions for completing the payment or reimbursement.

I understand that if I do not upload or email files to helpinghands@hemophiliafed.org now, there may be delays in processing this request.

Medical Verification

Must include medical proof of inhibitor

You may utilize this form or your own documentation. [CLICK HERE FOR FORM]

Please upload the medical verification / recommendation:

Medical Travel

Please utilize this form for medical travel reimbursement. [CLICK HERE FOR FORM]

Please upload the completed medical travel form.

Tutoring / Educational Supplies

Please utilize this form for educational reimbursement. [CLICK HERE FOR FORM]

Please upload the completed tutoring / educational supplies form.

You may submit the required documents by email: helpinghands@hemophiliafed.org