COVID-19 Relief Application for Patient Assistance

The Hemophilia Alliance Foundation is grateful to the Hemophilia Alliance for granting these funds to go to organizations serving patients during this unusual time. The intent of these funds is to go directly to patient assistance. For questions, please contact Grant Hiura at grataka@gmail.com

Eligibility

Grant applications currently are accepted from:

•Local, consumer-led organizations serving people with bleeding disorders
•Operating under one of these IRS tax exemptions: 501(c)(3) or 170(c)(1)

Organizations may apply for up to $6,500. You will be required to upload a PDF of a Statement of Financial Position (i.e. a balance sheet that reports assets, liabilities, and difference in totals as of the final moment of an accounting period) with your application that establishes a critical financial need, along with your IRS letter and your policy for patient assistance.

Use of Funds

Funds are to be used for patient financial assistance. Signature on this application attests to your agreement to this requirement. Priority will be given to organizations that can demonstrate the highest financial need.

The application form is below. All fields marked with an asterisk are required.

1. Is your organization an NHF chapter and/or HFA member organization?*
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.
2a. Name of applicant organization*
2b. Address of Organization*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code
2c. Address to send check if that differs from the organization’s address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code
2d. Name of Primary Contact Person*
2e. Telephone of Primary Contact Person*
2f. Email of Primary Contact Person*
2g. Name of Secondary Contact Person*
2h. Telephone of Secondary Contact Person*
2i. Email of Secondary Contact Person*
2j. Name of authorized signatory for the organization (e.g. Executive Director, Board Chair, Treasurer)*
3. What was your budget for patient assistance in 2019?*
4. How many requests for patient assistance did you receive in 2019?*
5. What is the total amount (in dollars) you have awarded for patient assistance in 2020 to date?*
6. Total amount requested ($6,500 maximum)*
Be sure to include the required attachments below.

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.

After clicking the “Submit” button below, a notification email, along with a link to a PDF of this form submission, will be sent to the email that you’ve entered into the “Email for primary contact person” field. However, the PDF can only be accessed from the same computer that was used to submit this form. This is a security measure to prevent unauthorized downloads. Therefore, if you are submitting this form on behalf of someone else and have input their email address into the “Email for primary contact person” field, then they will need to email the PDF link to you so that you can access it from your computer.

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.
Please attach the required document below.
Note: your document MUST be in PDF format. Attaching files in another format will result in a submission error.
Balance sheet statement of financial position*
Accepted file types: pdf.
IRS Tax Determination Letter*
Accepted file types: pdf.
Patient assistance policy/procedures*
Accepted file types: pdf.
To submit your application, click the “Submit” button below. If you’d like to save your progress and continue the application later, click the “Save and Continue Later” link. Doing so will take you to a page that will display a unique link. You’ll need this link to return to your application. You can copy and paste the link into a word processing document for safe keeping or you can have it emailed to an email address of your choosing.
Note that clicking the “Save and Continue Later” link will save all of your progress except for the file attachments. Those need to be attached just prior to submitting the application.

Save and Continue Later