PO Box 4214
Morgantown, West Virginia 26504
Phone 304-212-2616

Financial Assistance Application

Please review the Financial Assistance Policy guidelines for NHF National Chapters before submitting your application.
[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.
Section I: Basic Information
(Parent’s name(s) in case of a minor.)
First Name
Last Name
Country
Address Line 1
Address Line 2
City
State
Postal Code
(Where you can be reached for follow up questions.)
Type(s) of medical insurance?
Do you have medicaid?
(employer will not be contacted)
(employer will not be contacted)
The applicant is:
Is the Person/Child with a bleeding disorder a patient of an HTC (Hemophilia Treatment Center)?
Section II: Financial Assistance Request
West Virginia Chapter of NHF is able to provide a maximum of $500 funding per household, which also includes claimed dependents.
Include as much detail as possible.
Please be aware that West Virginia Chapter of NHF may need between 7 to 10 days to process a request.
Section III: Bill Payment Request
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.
Country
Address Line 1
Address Line 2
City
State
Postal Code
Please include a copy of the bill referenced in request and any other information necessary to support your request.
No file selected
This action supports multiple file uploads, but must select all items at the same time file upload.
Section IV: Submission
I certify that the information I have submitted is true and accurate to the best of my knowledge.
PO Box 4214
Morgantown, West Virginia 26504
Phone 304-212-2616

© West Virginia Chapter National Hemophilia Foundation 2021

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