Skip to main content

Financial Assistance Application

Please fill out all sections below to apply for Financial Assistance from the Hawaii 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 Hawaii to process your request.

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

APPLICANT INFORMATION
I have read and understand the Financial Assistance Program guidelines and policy
Is the Applicant on Disability?
FINANCIAL ASSISTANCE REQUEST
Are you or your family, paitent(s) of the Kapiolani Hawaii Hemophilia Treatment Center?
Are you or your family member affected with a bleeding disorder?
Have you or a family member had an hospitalizations in the last 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 Hawaii's financial assistance program in the past 3 calendar years?
Have you or your family attending NHF Hawaii's programs or events such as Camp Koko Ohana, NHF Hawaii Walk, Education Days or the General Membership Meeting?
NARRATIVE

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

NHF Hawaii is able to provide a maximum of $750 funding per household per year.

NHF Hawaii cannot provide funding directly to individuals.  However, if approved, NHF Hawaii will pay to a vendor directly.  Please list your bill payment information below and include copies of bills with contact information wherever possible.  Please review the Financial Assistance Program Guidelines and Policy for more information.

BILL PAYMENT REQUEST
I acknowledge/certify that the information I have submitted is true and accurate to the best of my knowledge.

Please email all supporting documentation & invoice to Billy Dannals, NHF Hawaii Executive Director, at bdannals@hemophilia.org

CONFIDENTIALITY

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

Information from the NHF Hawaii 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 Hawaii Chapter of the National Hemophilia Foundation.