Critical Relief Fund Open

Emergency Assistance Application

“Providing immediate support to individuals and families impacted by severe and rare bleeding disorders.”

Begin Request Form Review Verification Strict Requirements

Compliance Notice

Strict Verification Process

To ensure funds are distributed equitably and legally, strict clinical and financial documentation auditing is enforced.

Applications missing required clinical diagnosis verification or containing mismatched records will be automatically rejected.

Who can apply

Diagnosed patients with bleeding disorders, symptomatic carriers needing support, and legal guardians of minors with verified conditions.

What we cover

Rent/housing, utility bills, transportation for care, and emergency medical living expenses directly related to your condition.

Audit standard

Clinical diagnosis sheets and financial proofs must match your request exactly. Incomplete or mismatched packets are automatically rejected.

Processing

Applications are reviewed under strict clinical and financial auditing. Keep documents current and respond promptly if our team requests clarification.

Confidential Intake Portal

Emergency Relief Fund

Please enter your information carefully. All fields marked with an asterisk (*) are legally required for grant review under strict clinical auditing standards.

Primary Contact

Full Name *

Email Address *

Phone Number *

Date of Birth *

Role *

Patient Name (if different)

Address

Street Address *

City / State / Zip *

Clinical Diagnosis Verification

Are you or an immediate dependent treated clinically for a diagnosed bleeding disorder? *

Relief Request & Documentation

Assistance Type *

Amount Requested ($) *

Describe situation & urgency *

Payee Name *

⚠️ Audit Requirement: Please upload a combined PDF or clear images containing (1) your clinical hematology diagnosis sheet and (2) specific financial verifications corresponding to your emergency request.

Upload Mandatory Verification Proof *

Digital Signature (Full Name) *

By typing your name you certify that all clinical and financial information submitted is true and complete to the best of your knowledge.