Financial Assistance and Financial Aid Fund Application Form

Applicant Name (required)

Street Address (required)

City (required)

State (required)

Zip (required)

Email (required)

Phone 1 (required)

Phone 2

Date of Birth (required)

Parent/Guardian Name (if minor)

Financial need is being requested for?

Medical Alert ID

Financial Need Requested:

$

The applicant is:

An adult with a bleeding disorderA caretaker of someone with a bleeding disorder living in your householdA parent of a minor child with a bleeding disorder.Other

If Other, please explain:

Age of the person with bleeding disorder: (required)

How many family members in your household?
Adults:
Children:

Did someone refer you to the HSC Financial Aid Program? If so, please explain:

Have you applied for assistance from any other sources, and if so, what is the status of that application?

What is the applicant's annual household income?
Less than $15,000$16,000 - $35,000$36,000 - $50,000$51,000 or greater

Employer

Employer Name:

Employer Address:

Employer Phone:

Creditor

Please supply the business or individual whom HSC should make payment:

Name:

Complete Address:

Account/Invoice Number:

HTC and Physician

If you've applied for assistance from HSC in the past year, please provide the date:

This request will be forwarded to the Financial Assistance Committee of Hemophilia of South Carolina. In the interest of privacy, identifying information will be removed from the request and forwarded to a blinded committee for review. Additional information may be required. All payments will be made directly to the party that is owed the monies. Please attach all supporting information including copies of bills and payment page. Applicants will be informed of the outcome of the committee review.

To the best of my knowledge, I hereby certify that the above information is correct and accurate.
YesNo