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 Relief
Travel 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 Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age when diagnosed:
*
Clinical Diagnosis:
*
Parent/Guardian Information
Parent/Guardian Full Name (Type Applicant if you are the applicant)
*
First Name
Last Name
What is your relationship to the applicant?
*
applicant
parent
legal guardian
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail:
*
Phone:
*
Do you have the required documentation? Upload instructions will be displayed once the application has been submitted.
*
Yes
No
How many times a month do you travel for MEDICAL and/or THERAPY appointments?
*
Weekly
Bi-Weekly
Monthly (Once per month)
None of the Above
How far do you travel PER MONTH for these appointments?
*
Less than 20 miles
21 - 50 miles
51 - 100 miles
101+ miles
Please explain why you need the assistance
*
0/250
Signature
*
Type your name
*
First Name
Last Name
Today's Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Hour
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Minutes
AM
PM
AM/PM Option
Submit Application
Should be Empty: