Skip to main content
Who We Are
Our Mission
ACT Initiative
Board & Staff
Contact Us
Financial Statements
Bleeding Disorders
Overview
Fast Facts
What is a Bleeding Disorder?
History
Type of Bleeds
Women & Bleeding Disorders
Inhibitors
What is an Inhibitor?
Why Do Some Patients Develop Inhibitors?
How do I get tested for an inhibitor?
Treatment for Inhibitors
Immune Tolerance
Social and Financial Considerations
Research
Types
Hemophilia A
Hemophilia B
von Willebrand Disease
Other Factor Deficiencies
Treatment
Hemophilia A
Hemophilia B
Future Therapies
von Willebrand Disease
Other Factor Deficiencies
Healthcare Coverage
Hepatitis
HIV/AIDS
NHF-Guardian of the Nation's Blood Supply
Patient Notification System
Get Involved
Event Calendar
Advocacy
Washington Days
NE State Advocacy Days
Advocacy Tools & Resources
How a Bill Becomes a Law
6 Steps to Grass Roots Advocacy
Personal Health Insurance Toolkit
Nebraska Advocacy Workshop
Programs
Program Overview
Education Weekend
Adults with Bleeding Disorders Conference
FAB Women's Conference
PING! Parent Information & Networking Group
Teen Program
Industry Symposium
Men's Programs
Family Camp
Industry Partner Programs
Von Willebrand Disease Series
Harvest Festival
Kids Summer Camps
NYLI
Sickle Cell Education Day
Special Events
Infusion Bloody Mary Mix Off
Unite for Bleeding Disorders Walk
The Amazing GooseChase
Donate
Volunteer
Unite Your Way
Support & Resources
Hemophilia Treatment Centers
Financial Assistance Program
Community Voices in Research
Handi Library
Important Links
Medical ID Bracelets
Nebraska 2023 Needs Assessment
News
News
Big Red Factor Newsletter
Phone
(402) 742-5663
Phone
(402) 742-5663
Who We Are
Our Mission
ACT Initiative
Board & Staff
Contact Us
Financial Statements
Bleeding Disorders
Overview
Fast Facts
What is a Bleeding Disorder?
History
Type of Bleeds
Women & Bleeding Disorders
Inhibitors
What is an Inhibitor?
Why Do Some Patients Develop Inhibitors?
How do I get tested for an inhibitor?
Treatment for Inhibitors
Immune Tolerance
Social and Financial Considerations
Research
Types
Hemophilia A
Hemophilia B
von Willebrand Disease
Other Factor Deficiencies
Treatment
Hemophilia A
Hemophilia B
Future Therapies
von Willebrand Disease
Other Factor Deficiencies
Healthcare Coverage
Hepatitis
HIV/AIDS
NHF-Guardian of the Nation's Blood Supply
Patient Notification System
Get Involved
Event Calendar
Advocacy
Washington Days
NE State Advocacy Days
Advocacy Tools & Resources
How a Bill Becomes a Law
6 Steps to Grass Roots Advocacy
Personal Health Insurance Toolkit
Nebraska Advocacy Workshop
Programs
Program Overview
Education Weekend
Adults with Bleeding Disorders Conference
FAB Women's Conference
PING! Parent Information & Networking Group
Teen Program
Industry Symposium
Men's Programs
Family Camp
Industry Partner Programs
Von Willebrand Disease Series
Harvest Festival
Kids Summer Camps
NYLI
Sickle Cell Education Day
Special Events
Infusion Bloody Mary Mix Off
Unite for Bleeding Disorders Walk
The Amazing GooseChase
Donate
Volunteer
Unite Your Way
Support & Resources
Hemophilia Treatment Centers
Financial Assistance Program
Community Voices in Research
Handi Library
Important Links
Medical ID Bracelets
Nebraska 2023 Needs Assessment
News
News
Big Red Factor Newsletter
Financial Assistance Application
Please review the Financial Assistance Policy guidelines for NHF National Chapters before submitting your application.
I have read and understand the Financial Assistance Policy guidelines
[OPTIONAL] Completion of this application will automatically register you with the Nebraska Chapter of the National Hemophilia Foundation and place you on the mailing list.
I DO NOT wish to be placed on the mailing list.
Section I: Basic Information
Applicant's Name
(Parent’s name(s) in case of a minor.)
First Name *
Last Name *
Address
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Phone Number (Required)
(Where you can be reached for follow up questions.)
Email Address (Required)
Medical Insurance (Required)
Type(s) of medical insurance?
Do you have Medicaid?
Yes
No
Employer(s), if applicable
(employer will not be contacted)
Job Title, if applicable
Employer(s) Contact Information
(employer will not be contacted)
Marital Status, if applicable
Spouse’s Name, if applicable
Is spouse employed? If so, by whom?
The applicant is:
Person with a bleeding disorder
Parent of a minor child with a bleeding disorder
Other (write in below)
If Other, please describe
Type of bleeding disorder and/or other known medical diagnoses (Required)
Is the Person/Child with a bleeding disorder a patient of an HTC (Hemophilia Treatment Center)?
Yes
No
Have you or your family participated in any Nebraska Chapter programs or events such as camp, education weekend, Unite for Bleeding Disorders Walk, etc.? If no, please share barriers to participation. (Required)
Section II: Financial Assistance Request
6dhx18ltfe0s
Amount Requested
Nebraska Chapter of NHF is able to provide a maximum of $500 funding per household, which also includes claimed dependents.
Please describe your need for financial assistance (Required)
Describe how assistance will help resolve the current need. (Required)
Include as much detail as possible.
Please list any additional financial assistance requested from other organizations or programs for the current needs, dates, and outcomes of each request:
When are these funds needed? (Required)
Please be aware that Nebraska Chapter of NHF may need between 7 to 10 days to process a request.
Have you applied for financial assistance from Nebraska Chapter of NHF in the past?
Yes
No
If so, please provide the month and year.
Section III: Bill Payment Request
Company Name/Establishment (Required)
Nebraska Chapter of NHF cannot provide funding directly to individuals, but if approved, Nebraska 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 Nebraska Chapter of NHF Financial Assistance policy for more information.
Contact Name, if applicable
Account Number
Company Mailing Address
Country
Address Line 1
Address Line 2
City
State/Province
Postal Code
Company Contact Phone Number
Website, when available
Supporting Documentation
Please include a copy of the bill referenced in request and any other information necessary to support your request.
No file selected
Clear All Files
Click or drag here to add files
This action supports multiple file uploads, but must select all items at the same time file upload.
Section IV: Submission
I certify that the information I have submitted is true and accurate to the best of my knowledge.
I agree
eSignature (Required)
Resource Links