Emergency Financial Assistance Program Forms

*Please note: EFA Funds for 2024 have been exhausted. Please reach out in 2025.*

The Hemophilia Foundation of Southern California Emergency Financial Assistance program is available to help families and individuals in the bleeding disorders community in unusual, one-time, emergency situations which include but are not limited to emergency needs such as food, utility bills, transportation to treatment and rent support. This program is not meant to be used to remedy chronic financial problems. This program does not cover insurance premiums, deductible, co-payments, or co-insurance. Funding requests may be considered once a year for a maximum of $500 and preferably referred by a healthcare provider such as a Social Workers.

Applications must be filled out thoroughly and submitted with all supporting documentation to be considered for review. An incomplete application will be returned and will only delay the process. The entire process for an application to be reviewed and approved can take up to 7-10 business days. Please see the EFA policy for a more detailed description of our Emergency Financial Application process.

If you need any assistance or have any questions in completing the application, please contact Omar Torres at 626.765.6656 or omar@hemosocal.org. 

The Emergency Financial Assistance (EFA) application is available in four languages – English, Spanish, Chinese and Korean:

Please submit the completed application via email to omar@hemosocal.org.

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Eligibility

HFSC Members with bleeding disorders. Limited to 1 time per year. Please complete the application below and return to omar@hemosocal.org. Please take measurements carefully and allow up to 8 weeks to receive your ID once submitted.

Other resources available to the bleeding disorder community

If community members are in need of additional financial support, we often refer them to the following foundations/programs if eligible:

Pan Foundation

Offers

Copay Assistance Fund

• Deductibles, copays and coinsurance
• $2,900 per enrollment period
• Second grant available upon need and available funding

Premium Assistance Fund

• Applicable for one or more health plans
• $4,500 per enrollment period.
• Second grant available upon need and available funding

Grant Timeline

• Each eligibility period is for 12 months and new patients receive a 3-month lookback period
• If you run out of funding before your enrollment period ends, request a second grant if the disease fund is open

Qualifications for hemophilia programs

• Must be getting treatment for hemophilia.
• Must have health insurance that covers his or her qualifying medication
• Medication must be listed on PAN’s list of covered medications
• At or below 400% of the FPL
• Must reside and receive treatment in the United States. U.S. citizenship is not a requirement

Covers: Hemophilia A and B with and without inhibitors

PAN has developed a free resource to simplify the search for financial assistance for all charitable programs. It is web-based and accessible at www.fundfinder.org

• Funding availability updated hourly
• Information pulled from the websites of 8 charitable foundations
• Allows you to subscribe to email or text message notifications for specific disease funds openings and receive alerts when funding becomes available

The Assistance Fund (TAF)

Offers

• Copay assistance
• Premium assistance
• Incidental Medical Expenses
• Misc. out-of-pocket costs for incidental medical expenses (e.g., travel, infusion costs, nursing services)
• May receive assistance through the copay assistance programs and the insurance premium and incidentals programs simultaneously, if funding is available

Eligibility

• U.S. or permanent resident
• Income: up to 700% FPL, household
• Diagnosis: hemophilia A and B
• Insurance Status: Underlying primary coverage benefit
• Prescription: FDA-approved therapy

Covers: hemophilia with and without inhibitors, Thrombocytopenia

Programs are for a 12-month period with option to reenroll (opens in 4th quarter)

• New enrollments receive program approval for up to 15 months

To learn more about their programs and check if you qualify, click here.

Patient Advocate Foundation (PAF) Co-Pay Relief

• Covers copay, coinsurance, and deductible
• Maximum amount per year is $12,500

Eligibility

• 400% or less of FPL (adjusted for Cost of Living Index (COLI) and number in household)
• Open to all insurance types
• Must reside and receive treatment in the United States.

To learn more and apply for the program: https://copays.org/

The Colburn-Keenan Foundation

• Covers unexpected medical expenses, utility bills, cost of transportation to treatment, rent, medic alerts
• Maximum amount per year is $2,000

Eligibility

• Must be a US citizen and/or living permanently in the United States
• Must receive treatment for chronic inherited bleeding disorder in the United States.

To learn more and apply for the program: https://colkeen.org