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What is a Bleeding Disorder?
History of Bleeding Disorders
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Types of Bleeding Disorders
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Other Factor Deficiencies
Inhibitors & Other Complications
What is an Inhibitor?
Who is at Risk for Developing an Inhibitor?
How do you Know if you Have an Inhibitor?
Test Results
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PO Box 4214
Morgantown, West Virginia 26504
Phone
681-212-9255
Contact
Contact
Volunteer
Events
Donate
PO Box 4214
Morgantown, West Virginia 26504
Phone
681-212-9255
Contact
Who We Are
Our Mission
Act Initiative
Board & Staff
Contact Us
Financial Statements
Bleeding Disorders
What is a Bleeding Disorder?
History of Bleeding Disorders
Types of Bleeds
Future Therapies
Types of Bleeding Disorders
Hemophilia A
Hemophilia B
Von Willebrand Disease
Other Factor Deficiencies
Inhibitors & Other Complications
What is an Inhibitor?
Who is at Risk for Developing an Inhibitor?
How do you Know if you Have an Inhibitor?
Test Results
Treatment
Immune Tolerance
Treatment Costs & Financial Considerations
Blood Safety
Hepatitis
HIV/AIDS
NHF-Guardian of the Nation's Blood Supply
Patient Notification System
Research Endowment
Get Involved
Event Calendar
Advocacy
Washington Days
State Advocacy Day in Charleston
Advocacy Tools & Resources
How a Bill Becomes a Law
6 Steps to Grass Roots Advocacy
Personal Health Insurance Toolkit
Programs
Programs
Education Dinner Series
Annual Education Weekend
Family Camp
Kids Camp
NHF Bleeding Disorders Conference
Unite For Bleeding Disorders Walk
Provider & Volunteer of the Year Award
NYLI
Special Events
JNC Getting in the Game
NOW Conference
Donate
Donate
Moutaineer Circle
Volunteer
Unite Your Way
Contact Form
Support & Resources
Hemophilia Treatment Centers
Financial Assistance Programs
Seat Belt Rescue Facts
MedicAlert Jewelry
Community Voices in Research
HANDI Library
Important Links
COVID-19
News
News
Yearly Newsletter
Financial Assistance Application
Please review the Financial Assistance Policy guidelines for NHF National Chapters before submitting your application.
I have read and understand the Financial Assistance Policy guidelines
[OPTIONAL] Completion of this application will automatically register you with the West Virginia Chapter of the National Hemophilia Foundation and place you on the mailing list.
I DO NOT wish to be placed on the mailing list.
Section I: Basic Information
Applicant's Name
(Parent’s name(s) in case of a minor.)
First Name
Last Name
Address
Country
Address Line 1
Address Line 2
City
State
Postal Code
Phone Number (Required)
(Where you can be reached for follow up questions.)
Email Address (Required)
Medical Insurance (Required)
Type(s) of medical insurance?
Do you have medicaid?
Yes
No
Employer(s), if applicable
(employer will not be contacted)
Job Title, if applicable
Employer(s) Contact Information
(employer will not be contacted)
Marital Status, if applicable
Spouse's Name, if applicable
Is spouse employed? If so, by whom?
The applicant is:
Person with a bleeding disorder
Parent of a minor child with a bleeding disorder
Other (write in below)
If Other, please describe
Type of bleeding disorder and/or other known medical diagnoses (Required)
Is the Person/Child with a bleeding disorder a patient of an HTC (Hemophilia Treatment Center)?
Yes
No
Have you or your family participated in any West VirginiaChapter programs or events such as camp, education weekend, Unite for Bleeding Disorders Walk, etc.? If no, please share barriers to participation. (Required)
Section II: Financial Assistance Request
Amount Request (Required)
West Virginia Chapter of NHF is able to provide a maximum of $500 funding per household, which also includes claimed dependents.
Please describe your need for financial assistance (Required)
Describe how assistance will help resolve the current need. (Required)
Include as much detail as possible.
Please list any additional financial assistance requested from other organizations or programs for the current needs, dates, and outcomes of each request:
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When are these funds needed? (Required)
Please be aware that West Virginia Chapter of NHF may need between 7 to 10 days to process a request.
Have you applied for financial assistance from West Virginia Chapter of NHF in the past? (Required)
If so, please provide the month and year.
Section III: Bill Payment Request
Company Name/Establishment (Required)
West Virginia Chapter of NHF cannot provide funding directly to individuals, but if approved, West Virginia Chapter of NHF will pay a vendor directly. Please list your bill payment information below and include copies of bills with contact information wherever possible. Please review the West Virginia Chapter of NHF Financial Assistance policy for more information.
Contact Name, if Applicable
Account Number
Company Mailing Address
Country
Address Line 1
Address Line 2
City
State
Postal Code
Phone Company Contact Number
Website, when available
Supporting Documentation
Please include a copy of the bill referenced in request and any other information necessary to support your request.
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Section IV: Submission
I certify that the information I have submitted is true and accurate to the best of my knowledge.
I Agree
eSignature (Required)
Resource Link
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Steps for Living
HemAware
Victory for Women
Better you Know
Unite For Bleeding Disorders Walk
Unite Your Way
CDC