Financial Assistance Application

Please fill out all sections below to apply for Financial Assistance from the Colorado Chapter of NHF.  Please remember that financial assistance depends on the availability of funds and applicant eligibility.  Funding is not guaranteed.  Applicants should allow at least 7 business days for NHF Colorado to process your request.

Please review the Financial Assistance Policy guidelines for NHF National Chapters before submitting your application.
Completion of this application will automatically register you with the Colorado Chapter of the National Hemophilia Foundation and place you on the mailing list.
Section I: Basic Information
(Parent’s name(s) in case of a minor.)
First Name
Last Name
Country
Address Line 1
Address Line 2
City
State
Postal Code
(Where you can be reached for follow up questions.)
Type(s) of medical insurance?
Do you have Medicaid?
(employer will not be contacted)
(employer will not be contacted)
The applicant is:
Is the Person/Child with a bleeding disorder a patient of an HTC (Hemophilia Treatment Center)?
Section II: Financial Assistance Request
Colorado Chapter of NHF is able to provide a maximum of $500 funding per household, which also includes claimed dependents.
Include as much detail as possible.
Please be aware that Colorado Chapter of NHF may need between 7 to 10 days to process a request.
Have you applied for financial assistance from Colorado Chapter of NHF in the past?
Section III: Bill Payment Request
Colorado Chapter of NHF cannot provide funding directly to individuals, but if approved, Colorado Chapter of NHF will pay a vendor directly. Please list your bill payment information below and include copies of bills with contact information wherever possible. Please review the Colorado Chapter of NHF Financial Assistance policy for more information.
Country
Address Line 1
Address Line 2
City
State
Postal Code
Please include a copy of the bill referenced in request and any other information necessary to support your request.
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I certify that the information I have submitted is true and accurate to the best of my knowledge.
1385 S. Colorado Blvd. Suite #610
Denver, CO 80222

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