Patient Assistance Fund - Request Form

The BMT InfoNet Patient Assistant Fund (PAF) assists patients and caregivers with living expenses during treatment.

Grants are $200. We cannot accommodate larger grant requests.

Who is eligible for Assistance

Patients who in the past 24 months, have had
- an autologous transplant
- an allogeneic transplant with a RELATED donor
- CAR T-cell therapy
Patients with graft-versus-host disease (GVHD) who are at least 12 months post-transplant

Application Process:

Application for funds must be completed by a social worker or transplant center personnel who certifies that the patient is in need of financial help.
Please wait until day one of transplant or CAR T before applying.
ALL sections of the application form must be completed to be considered.
If you have questions, please call 888-597-7674 or email Marsha at marsha@bmtinfonet.org.

Evaluation/Decision

Patient and Transplant personnel will be notified via email when the application is received.
Fully completed applications will be reviewed within two weeks of receipt. Incomplete applications will delay review.
Applicants and transplant personnel will be notified via email of the decision following review.

Disbursement of Funds

Funds will be dispersed in the form of a check made out to the patient or caregiver and mailed to the address indicated on the form.

Please complete the following application with the patient/caregiver and provide as much detail as possible. Failure to complete the application in full will result in delay of review and funding.

Patient or Parent/Guardian requesting Funds

First Name (of patient or guardian requesting funds)

Last Name (of patient or guardian requesting funds)

Email of Adult Requesting Funds

We strongly encourage you to include an email for adult requesting funds.

Phone Number

Phone Type

Cell

Landline

Street Address

Street Address Line 2

City

Postal Code

State/Province

Country

Birth Date - for adult requesting funds

Gender of person requesting funds

Patient Info & Relationship

Relationship to Patient

Relationship Other

Patient First Name

Patient Last Name

Patient's Birthdate

Diagnosis Info

Diagnosis

Type in diagnosis to see list or select Other and complete the disease description.

Disease Description

If your disease was not listed above enter it here.

Disease Subtype

What type of therapy did you/patient have or will have?

Transplant - bone marrow, stem cell or cord blood

CAR T-Cell Therapy

Transplant Info

Number of Transplants

Date of Transplant

Patient Age at time of transplant

Age of person requesting funds at time of transplant. Not the Patient.

Transplant Type

Donor type

Type of cells used

Match Criteria (MRT)

Transplant Center Name

Grant

Names and Relationship of family members or friends utilizing funds

Provide details why funding is needed.

Itemize all SOURCES and AMOUNTS of monthly household income

Has the patient applied for funding from other organizations

Yes

List of other organizations applied for funds

Will the check be sent to a different address than listed above? If yes, please provide other address below.

Amount Requested

Grants are available in amounts up to $200.

Center Staff Person Information

First Name

Last Name

Degree

Phone Number

Position at the Center

Verification

Name of your center

Name of person making this affirmation

I confirm this information to be accurate.

The above information is accurate

Date

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