Financial Assistance Application

To be considered for financial assistance, the applicant must have:

A completed Financial Assistance Application (see form below)
A confirmed PFIC or related disease (including BRIC) 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 program waiver (See Program “Terms and Conditions”)

Download Terms & Conditions Waiver

Additional Information About the Financial Assistance Application

A detailed description of need is highly recommended. Your description of need helps PFIC Network assess the level of need among applicants.
You may apply as many times as needed throughout the year. However, PFIC Network will award assistance a maximum of one (1) time per calendar year per family.
The PFIC Network will ONLY make payments directly to third party service providers, not to the family directly. (Ex: For assistance with an electric bill, PFIC Network will make the payment directly to the electric company).
The third-party bill(s) MUST be provided, if approved, before any assistance will be provided.
PFIC Network will not award funds for emergency services, such as utility shutoff notices.
The PFIC Network Board of Directors has final approval of all awards.
If you need assistance applying or securing the required documentation to submit an application, please contact us.

Download a Printable Application

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

What is needed?*

Please provide a detailed list of specific bills and expenses to be covered.

Total Amount Requested (in USD)*

Total award may not exceed $1000 USD

Explanation of need*

Please describe how PFIC-related expenses affect your family.

CAPTCHA

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