Patient Assistance Grant Application CompanyThis field is for validation purposes and should be left unchanged.Please note: ALL items and fields are REQUIRED and must be completed!1. State applicant organization typeLocal Chapter/Association/OtherHemophilia Treatment CenterNational 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.a. Name of applicant organizationb. 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 persone. Telephone of primary contact personf. Email of primary contact person g. Name of secondary contact personh. Telephone of secondary contact personi. Email of secondary contact person 3. Is this a collaborative grant with another/other eligible organization(s) as defined in the grant guidance? Yes No 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; $10,000 maximum for national organizations. Note: If both a project grant and a patient assistance grant are being submitted, please carefully read the Grant Guidance for maximum amounts that can be requested. a. Amount for project.b. If this is a collaboration grant, list collaborating organizations and how much is requested for each5a. Name of authorized Individual5b. Signature of authorized Individual6. Organization description: Include brief description of mission, geographic service area, and # patients/families served. If this is a collaboration grant, describe briefly for each organization. 7. Brief description of the need that the grant addresses. For example: “The chapter/association/HTC has identified 20 families who are not able to access care due to insurance/transportation obstacles, etc.” 8. Overall description of the patient financial assistance process. Attach your patient assistance policy (see below). Click here for example of a patient assistance policy from Grant Guidance.9. Itemized Budget and Budget Narrative Budget: Must be itemized with each item and amount, including personnel. For collaboration grant, include all collaborators and their relevant allocations of funds. Click here for sample or see sample budget in the Grant Guidance.Click on (+) to add more rows if needed.Description$ Amount Add RemoveTotal Amount RequestedBudget Narrative: Clearly justify all budget line items. You MUST estimate the number of patients/families expected to be helped by these funds and the average amount of funds per patient/family. Include an explanation of personnel, name, role on the project, and salary/hourly charge. NOTE: Personnel expenses up to but not exceeding 10% of the total grant request may be included for the purpose of administering patient assistance funds. 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, SUBMIT ELECTRONICALLY BY PRESSING THE “SUBMIT” BUTTON AT THE BOTTOM OF THIS FORM. YOU WILL RECEIVE AN ELECTRONIC CONFIRMATION OF RECEIPT.Acknowledgement(Required) 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). 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.Copy of your IRS Determination Letter OR 501(c)(3). If collaboration grant, submit for each organization. Drop files here or Select files Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB. Copy of your organization’s W-9. For collaboration grant, only submitting organization needs to include their W-9. Drop files here or Select files Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB. Patient/consumer assistance guidelines (If collaboration grant, submit for each organization unless guidelines from the submitting organization will be utilized for all collaborating institutions.) Drop files here or Select files Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB. Letters from collaboration entities (required if collaboration grant) Drop files here or Select files Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB.
