Financial Assistance Application

Important Program Notes

Maximum grant award is $1000 USD
A detailed description of need is highly recommended
Please submit documentation of bills/invoices you would like assistance with
PFIC Network makes payments directly to third-party service providers, not to families directly (example: for assistance with an electric bill, we pay the electric company directly)
We cannot provide assistance for emergency time-sensitive services, including utility shut-off notices
Applicants must provide documentation supporting their application prior to receiving funds. PFIC Network will not disburse funds without documentation.

If you need assistance applying or securing the required documentation to submit an application, please contact us.

PFIC Network Financial Assistance Application

Use this form to apply for financial assistance. If you need assistance filling out this form, please contact info@pfic.org

"*" indicates required fields

Applicant Information

Applicant Name*

First Last

Applicant Email Address*

Applicant Phone Number

Applicant Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Age of Applicant*

Relationship of Applicant To PFIC (including BRIC and related diseases)*

Patient

Parent/Guardian of Patient

Caretaker of Patient

Spouse/Partner of Patient

Dependant of Patient

Family Member of Patient

Other

Patient Name*

First Last

Patient Age*

Parent/Guardian's Name (if patient is a minor)

Physician Information (Provider for PFIC treatment)

Physician Name:*

Hospital/Clinic Where Patient Is Treated For PFIC*

Physician Phone Number:

Description of Need

Please provide a detailed list of specific bills and expenses to be covered by the grant.*

Total Amount Requested (in USD)*

Total award may not exceed $1000 USD

Explanation of need*

Please describe how PFIC-related expenses affect your family.

File Upload

Please upload documentation of the bills/expenses you would like assistance paying, such as invoices or receipts.

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 512 MB, Max. files: 10.

Have you previously received a Financial Assistance Grant from PFIC Network?*

Yes

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**Applicants must provide documentation supporting their application prior to receiving funds. PFIC Network will not disburse funds without documentation.**

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