Financial Assistance Application

To apply for financial assistance, the applicant must have:

  • A completed Patient Assistance Program Application
  • A confirmed PFIC diagnosis, confirmed by physician or casework on
  • hospital/clinic letterhead; or Medical Eligibility form completed by a physician (**May substitute this requirement by providing public social media page or CaringBridge page sharing information about PFIC diagnosis and/or journey at the decision and discretion of the PFIC Executive Director**)
  • A signed Waiver (See Program “Terms and Conditions”)
  • An explanation of specific financial need
pfic patient parent

Additional Information Regarding Application Process

  • A detailed description of need is highly recommended, as it will be used to determine level of need among applicants
  • You may apply as many times as needed throughout the year. However, a family will be awarded assistance a maximum of one (1) time per calendar year.
  • The PFIC Network will ONLY make payments directly to third party service
  • providers, not to the family directly. (For example: A request is made for
  • assistance for electric bill. If approved, PFIC will make payment directly to
  • electric company).
  • The third-party bill(s) MUST be provided, if approved, before any assistance will
  • be provided.
  • Assistance cannot be used for emergency services, including utility cut off notices.
  • Final approval of financial assistance is determined on a case by case basis by the PFIC Network Board of Directors.

**If applicant is awarded scholarship, documentation of the requested bill to be paid must be
provided to PFIC Network before payment will be awarded.**