GUIDELINES
Purpose:
The Hemophilia of North Carolina (HNC) Financial Assistance Program is part of HNC's continuing effort to improve the quality of life of individuals and families affected by bleeding disorders. This Program provides funds to eligible individuals and families who need assistance with:
- Expenses incurred in the care, treatment, or prevention of a bleeding disorder, and/or
- Basic living expense emergencies.
Note: This program is intended to help individuals and families who have exhausted all other sources of assistance and for whom no other funds are unavailable.
Eligibility:
To be eligible for this program you must meet the following criteria:
- You must be a resident of North Carolina; OR receive treatment from one of the three (3) federally funded Hemophilia Treatment Centers (HTCs) within North Carolina: Wake Forest University School of Medicine, University of North Carolina at Chapel Hill School of Medicine, and the East Carolina University Brody School of Medicine.
- You must be the parent or caregiver of a minor child who lives in your home and who has a diagnosis of a bleeding disorder; OR be an individual with a diagnosis of a bleeding disorder.
- You must have requested assistance from at least TWO (2) other agencies before applying to HNC, and provide contact information for those agencies and the status of your requests.
- You must complete all sections of the application thoroughly and accurately. (If a question does not apply, it should be marked Not Applicable [N/A]).
Administration:
- Financial assistance depends on the availability of funds and applicant eligibility. Funding is not guaranteed. Applicants should allow at least two weeks for HNC to process their request.
- Assistance is limited to one grant per calendar year and a maximum of $500. In the presence of special circumstances, the HNC Board of Directors will review exceptional requests.
- Disbursements will be made only to creditors identified in the application and that have been verified by HNC. No payments will be made directly to applicants.
Request Process:
- Application forms are available by calling the HNC office at 800-990-5557, by emailing a request to info@hemophilia-nc.org, or by downloading (pdf, 184kb) from www.hemophilia-nc.org.
- Completed applications and a copy of the bill must be submitted by mail to:
Hemophilia of North Carolina
PO Box 70
Cary, NC 27512
or faxed to (919)319-0016.
- The HNC staff will review applications for completeness, check references, and consider the date the funds are needed in order to determine the urgency of the request.
- Incomplete applications will be returned to the applicant with an explanation of why it was returned and a description of the information still required.
- Complete applications will be sent to the HNC Board of Directors for review.
- If the application is approved, HNC staff will notify the applicant, and a check will be mailed to the creditor identified on the application.
- If the application is rejected, HNC staff will notify the applicant with an explanation.
- HNC staff will update its Financial Assistance Program records and add the applicant to the HNC database for future communications. (Applicants may opt out of being added to the HNC database by checking the "Opt Out" box on the application form.)
Confidentiality:
- Applications and information pertaining to funding requests are considered confidential.
- Information from HNC Financial Assistance Program applications may 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 purpose other than that for which it was collected. At no time will personal information be shared with any individual, company or organization outside of Hemophilia of North Carolina.
Revised December 19, 2007
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