Patient Assistance Grant Application

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1. State applicant organization type*

2. Contact Information
In the event that the staff who submitted the grant request leaves the organization during the grant period, the Foundation needs the contact information for a second individual who is responsible for the project.

a. Name of applicant organization*

b. Address of organization*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

c. Address to send check if that differs from the organization’s address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

d. Name of primary contact person*

e. Telephone of primary contact person*

f. Email of primary contact person*

g. Name of secondary contact person*

h. Telephone of secondary contact person*

i. Email of secondary contact person*

3. Is this a collaborative grant with another/other eligible organization(s) as defined in the grant guidance?*

Yes

Please list name(s) of collaborating organization(s) in the space provided below

4. Amount Requested:
$8000 maximum for Chapter/Association/Other and Hemophilia Treatment Centers; $10,000 maximum for national organizations and the eight Federally-designated and funded regional core centers.

a. Amount for project.*

b. Amount for patient/consumer assistance.

c. For collaboration, list partners and how much is included for each.

5a. Name of authorized Individual*

5b. Signature of authorized Individual*

6. Organization description: *brief* description of mission, geographic service area, # patients or families served.*

7. *Brief* description of the project and/or patient/consumer-financial assistance you propose. For patient/consumer-family financial assistance programs, *attach* your criteria or guidelines for awarding assistance. * (Click here for sample of Patient Assistance Policy)

8. *Brief* description of the need that the project addresses. Example: the chapter/association/HTC has identified 20 families who are not able to access care due to insurance/transportation, etc.*

9. Concisely state the specific outcomes or measurable objectives of the project. THESE MUST BE STATED AS SMART OBJECTIVES: Specific, Measurable, Achievable, Relevant, and Time-bound. Refer to Grant Guidance for suggestions how to write SMART objectives.*

10. How will you measure the success of the project?*

11. How will the project strengthen your organization?*

12. Itemized Budget and Budget Narrative * - Format: Click here for sample. Budget: must be itemized with each item and amount including personnel names. Budget and narrative apply to HAF funds only. Click on (+) to add more rows if needed.

Item Description

$ Amount Requested

$ Other Funding Source

Total Amount Requested*

Budget Narrative: Include explanation of personnel, name, role on project, salary/hourly charge and all equipment, travel, supplies, other with details.*

Be sure to include required attachments specified in the Guidance.

Note: your uploaded documents MUST be in PDF, JPG, or JPEG format. THE APPLICATION MUST BE SUBMITTED ONLINE. ONCE COMPLETED, THE REPORT MUST BE SUBMITTED ELECTRONICALLY BY PRESSING THE “SUBMIT” BUTTON AT THE BOTTOM OF THIS FORM. YOU WILL RECEIVE AN ELECTRONIC CONFIRMATION OF RECEIPT.

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Acknowledgement*

The grant applicant acknowledges and agrees to comply with all applicable state and federal laws including but not limited to the Federal Anti-Kickback Statues as found in Section 1128 D(b) of the Social Security Act and 42 U.S.C. Section 1330a-7b(b).

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Note 1: After clicking the “Submit” button below, a notification email will be sent to the Primary Contact Person’s email address that includes a copy of your report in PDF format. The PDF will be attached to the email. Note 2: If, after submitting the form, you don’t receive a notification email in your Inbox, then please check your spam folder and whitelist the email address info@hemophiliaalliancefoundation.org. YOU ARE RESPONSIBLE FOR MAKING SURE YOU RECEIVE THIS ACKNOWLEDGEMENT OF RECEIPT.

IRS Determination Letter*

Drop files here or