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”)

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.

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