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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 14 business days for NHF Colorado to process your request.

Completion of this application will automatically register you with the Colorado Chapter of the National Hemophilia Foundation and place you on the mailing list.

I have read and understand the Financial Assistance program guidelines & policy.
APPLICANT INFORMATION
Is the Applicant on Disability
FINANCIAL ASSISTANCE REQUEST
Are you or your family, patient(s) of the University of Colorado Hemophlia & Thromobosis Center?
Are you or a family member affected with a bleeding disorder?
Have you or a family member had any hospitalizations or surgeries in the past year?
Does the applicant have mobility issues, chronic pain or joint replacement issues as a result of a bleeding disorder?
Does the applicant have any other medical conditions besides a bleeding disorder?
Have you applied to other financial assistance programs for your current need?
Have you or your family applied to NHF Colorado's financial assistance program in the past 3 calendar years?
Have you or your family attended NHF Colroado's programs or events such as Mile High Summer Camp, Family Camp, Education Dayz or the Colorado Walk for Hemophilia?
NARRATIVE

Please use as MUCH detail as possible to describe your request.  Applications without significant detail will be sent back for follow up.

NHF Colorado is able to provide a maximum of $500 funding per household per year.

NHF Colorado cannot provide funding directly to individuals.  However, if approved, NHF Colorado will pay directly to a vendor.  Please list you bill payment information below and upload copies of bills below with contact information wherever possible. 

No file selected
BILL PAYMENT REQUEST INFORMATION
I certify that the information I have submitted is true and accurate to the best of my knowledge.
CONFIDENTIALITY

Applicant names and information pertaining to funding requests are considered confidential to the full extent permitted by law.

Information from the NHF Colorado Financial Assistance Program applications maybe be compiled for statistical purposes and for compliance with local, state, federal or affiliate organization requirements.  However, any publication of this data will be in aggregate form only and will not include names or any other information that could be used to identify individual applicants or recipients.

No personal information will be used or disclosed for any purposes other that that for which it was collected without the applicant's written permission.  At no time will personal information be shared with any individual, company, and/or organization outside the Colorado Chapter of the National Hemophilia Foundation.