Assistance Request Form


No request for personal assistance will be considered unless currently registered with AHF.

FAMILY INFORMATION:

Parent Name Today's Date

Street Address Home Phone

City Zip Other Phone

E-Mail Address


CHILD INFORMATION:


Affected Child's Name Birthday

Primary Diagnosis

How Rare Is This Condition?

What do you need AHF to consider assisting you with?

* Estimate of equipment cost (Invoice or order information) must be attached, or sent to us within 30 days of request.
(Max file upload size 1mb)

* Medical necessity letter from doctor or therapist must be attached, or sent to us within 30 days of request.
(Max file upload size 1mb)

* To have medical bills considered, medical statements showing insurance payments must be attached, or sent to us within 30 days of request.
(Max file upload size 1mb)


* For conference assistance you must fill out “AHF Request for Conference Scholarship” form.

What previous assistance have you received from AHF. This will not affect this current request, it is just for our data.

What other agency(ies) have you asked to help with this request, if any?



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