Emergency Services

Emergency Services

One of the programs the Hemophilia Foundation of Great Florida has designed to help people with bleeding disorders is the Emergency Financial Assistance Program (EFAP). The Hemophilia Foundation Emergency Financial Assistance Program funds are intended for a crisis situation or unforeseen emergency.  All requests for assistance with rent, utilities, mortgage, medical bills & medical equipment must be in the name of the person with the bleeding disorder, unless the person with the bleeding disorder is under the age of 18. Therefore, the names of family members and other relatives are prohibited for financial assistance.

Before filling out the application, please read the Emergency Financial Assistance guidelines below:
Emergency Assistance Guidelines.
​All bills must be in the applicant's name, unless the applicant is a minor, and the address on
the bill must be the same on the lease/mortgage contract.

All requests for dental assistance must be accompanied with a medical clearance letter from your Hematologist

​Please send ALL supporting documents by fax to 407-629-9600 or email to dinarichardson@hemophiliaflorida.org.

The Hemophilia Foundation of Greater Florida does NOT assist with any of the following:

  • Car payments, insurance , repairs, or rentals
  • Cable (TV)
  • Auto tires, or tag/registration fees
  • Home owners dues/fees or insurance premiums
  • Home phone or cell phone fees
  • Durable medical equiptment (exception: if insurance does not provide coverage)
  • Household modifications or rennovations
  • Furniture
  • School uniforms
  • Clothing or shoes
  • Airline tickets
  • Credit card debt or payments
  • Medical bills (more than 2 months old)

Emergency Financial Assistance Form
All boxes are required and must be filled out with supporting documents attached prior to processing. Documents needed for EVERY application: Recent tax return or 1099; last 2 months bank statements; copy of the bill in which you are requesting assistance with paying;  any other documents that support  your request.
Additional documentation for rental assistance: Current lease agreement.
Additional documentation for dental assistance: Letter from your HTC; treatment plan for services.
​For non-applicable boxes, please fill with 'N/A', 'None', or '0'.

Requester Information

Employer Information Information

Referral and Hematology Information

Who referred you to HFGF for assistance? *

Household Information

Affected Household Member

Person in household affected by a bleeding disorder*

All Others in Household

Please attach any additional household members in a separate document.

Monthy Income

If one does not apply, mark as $0.

Monthy Expenses

If one does not apply, mark as $0.

Assistane Request

Agreement and Consent

I certify that the information I have provided in the above is true and correct. I consent to the release of pertinent information contained in this application to the Hemophilia Foundation of Greater Florida, Inc., other social service agencies which distribute emergency financial assistance, the company or individual to receive funds as necessary to complete the services to my household, or to provide statistics on emergency assistance, or as a guard against duplicate assistance. I also consent to release of patient information to the federal government and those utility companies which require documentation of the recipients' funds. I acknowledge that I have read the Emergency Financial Assistance Guidelines above and will adhere to them.

I agree