Financial Assistance Program

The Midwest Hemophilia Association (MHA) Financial Assistance Program helps eligible individuals and families affected by bleeding disorders with:

• Certain bleeding-disorder–related expenses (such as medical equipment)
• Essential living costs, including rent, utilities, groceries, fuel, vehicle repairs, and vehicle payments

This program is intended for those who have exhausted other available resources and must have requested assistance from at least two other agencies before applying.

Applicants must live in MHA’s service area (Kansas and western Missouri) and/or be a current patient of the Kansas City Regional Hemophilia Treatment Center, and must complete the application fully and accurately.

Assistance is not guaranteed, is based on available funds, and is generally limited to up to $1,000 per household once every two years. Approved payments are made directly to verified creditors, not to applicants. The application and the full guidelines are available for download at the bottom of the page.

1. Applicant Information

Applicant

First Name Last Name

Phone

Email

Address

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Please Note: Parents of adult children with a bleeding disorder or spouses of a person with a bleeding disorder may NOT apply on behalf of their child or spouse unless they provide an explanation of disability that prevents the adult with a bleeding disorder from applying on their own behalf.

Explanation

2. List ALL individuals currently living in the household including non-family members.

*TYPES OF RELATIONSHIPS CAN INCLUDE: self, spouse, son, daughter, parent, sibling, roommate, etc.

To add more individuals, click the “+” (Add Row) button at the end of the table.

First Name

Last Name

Date of Birth

Does this person have a bleeding disorder?

Type of bleeding disorder

Relationship to person with bleeding disorder

 

Add Remove

To add more individuals, click the “+” (Add Row) button at the end of the table.

3. Referral Information

Who referred you to MHA?

May we contact them?

Yes

No

Referrer's Phone

Name of Hemophilia Treatment Center where patient(s) is seen

If patient(s) are NOT seen at an HTC, where is medical care received for their bleeding disorder?

4. Request for Assistance

Amount Requested

Date Needed By

MM slash DD slash YYYY

Describe the reason/situation for the request in as much detail as possible

5. MHA requires applicants to first seek assistance from two agencies before applying for this program.

Please identify these agencies (Example: church, local charity, HFA, etc.)

Agency Name 1

Phone

Status (Approved, Pending, Denied)

 

Add Remove

Agency Name 2

Phone

Status (Approved, Pending, Denied)

 

Add Remove

6. Creditor Information

(The business/individual to whom MHA should send the check if approved)

Creditor Name

Creditor Phone #

Account #

Creditor Address

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

7. Employment/Income Information

Employer

Employer Phone #

Employer Address

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

List of employers of other household members

Add Remove

To add more employers, click the “+” (Add Row) button at the end of the table.

TOTAL Monthly Household Income

List ALL income from ALL other members of the household. Sources of income should include: employment, wages, unemployment, SSI/SSDI/SSD, Food Stamps, spousal/child support, assistance from relatives, etc. MHA reserves the right to request a copy of your most recent tax return for verification of income.

Past Assistance

Have you applied for assistance from MHA in the past year?

Yes

No

If YES, please provide month/year

Submittal of Bill:

All pages of the bill in question must be submitted to MHA before the application for financial assistance can be reviewed.

Attach complete documentation of the bill:

Drop files here or Select files

Max. file size: 50 MB.

PLEASE NOTE:

• The Midwest Hemophilia Association (MHA) grants are never made directly to applicants/individuals, only to creditors that can be verified by MHA.
• Assistance is limited to a maximum of $1000 per household. Assistance is limited to once every two years.
• Personal information will not be used or disclosed for purposes other than those for which it was collected.

By signing below, you verify that the information you have provided to be true and accurate.

Signature

Date

MM slash DD slash YYYY

MHA Financial Assistance Program Guidelines

MHA Financial Assistance Application

Medic Alert ID

A Medical Alert ID is essential for people with bleeding disorders. Wearing a Medical ID ensures emergency responders and hospital staff have up-to-date medical information the moment they need it to make informed decisions about treatment and care.

To apply for a Medic Alert ID due to financial hardship please complete the form above OR click on HFA’s Helping Hands: Items Assistance

The MHA Financial Assistance Program is supported by charitable donations from the following: