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 firstname.lastname@example.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
- 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: copy of every working person in the households paycheck stub, 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’.