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: *

Durable Medical Equipment Incontinence Supplies Travel Assistance Enteral Feeding Supplies Adaptive Vehicle Assistance Financial Relief
What type of DME are your requesting?
Your response allows us to ensure we have the item in our inventory
Applicant Information
Full Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Date Date Picker Icon
Age when diagnosed or when illness began: *
Clinical Diagnosis: *
Parent/Guardian/Caregiver Information
What is your relationship to the applicant? *
Full Name: *

First Name Last Name

Address: *

E-mail: *
Phone: *
Date of Birth: *

Month Day Year Date Picker Icon
Do you have the required documentation? Upload instructions will be displayed once the application has been submitted. *
Visit https://hereforareason.org/program-requirements to review the requirements
Is there anything else we should know?
Application Requirements and Terms
Should be Empty:

Applicant Information