HFAR Application for Assistance

HFAR Assistance Application

In order to be considered for services, we must receive all required documentation within 30 days of your submitted application. Incomplete applications will be denied and you will be required to resubmit your application.
Select the program area you are applying for:*

Financial ReliefTravel Assistance
What type of DME are your requesting?
Your response allows us to ensure we have the item in our inventory
Applicant Information
Applicant Full Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Age when diagnosed:*
Clinical Diagnosis:*
Parent/Guardian Information
Parent/Guardian Full Name (Type Applicant if you are the applicant)*

First NameLast Name
What is your relationship to the applicant?*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail:*
Phone:*
Do you have the required documentation? Upload instructions will be displayed once the application has been submitted.*
How many times a month do you travel for MEDICAL and/or THERAPY appointments?*

WeeklyBi-WeeklyMonthly (Once per month)None of the Above
How far do you travel PER MONTH for these appointments?*

Less than 20 miles21 - 50 miles51 - 100 miles101+ miles
Please explain why you need the assistance*

0/250
Signature*

Clear
Type your name*

First NameLast Name
Today's Date

MonthDayYear
DateHourMinutesAM/PM Option
Should be Empty:

Applicant Information