Screen Reader Mode Icon

Please read thoroughly, before proceeding:

The Western Pennsylvania Bleeding Disorders Foundation realizes hardship can strike at any time. This fund will provide gift cards for groceries, $100 per family member, up to $400 per family, for members who are in urgent need of food. This program is not intended to remedy chronic financial issues or supplement income on a regular basis.
 
If the household has already received grocery gift cards from the Fund in the current fiscal year (July 1-June 30), we ask that you reach out to a social worker at the Hemophilia Center of Western PA to discuss your situation and find out if other resources are available, before applying for another gift card. If you are not a patient of the Hemophilia Center of Western Pennsylvania, please reach out to Foundation Staff at 724-741-6160 or info@wpbdf.org for assistance. You will need to provide proof that additional resources were outreached before requesting another gift card. 
 
Eligibility:
1. The applicant is a member of the Western Pennsylvania Bleeding Disorders Foundation with a bleeding disorder or lives in the same physical household as a person with a bleeding disorder.

2. The household income has significantly decreased and applicant is unable to pay essential household bills.

3. If the household has already received grocery gift cards from the Fund in the fiscal year (July 1-June 30), proof that additional resources were outreached before requesting another gift card is required. Applications will be reviewed on a case-by-case basis.
 
Application Process:
1. Answer all required questions on this form and submit the completed application.

2. Confidential application call: A WPBDF staff member will review the application and outreach the applicant to confirm information. Staff may also share additional resources that may help the household.

3. Efficient, effective help: When the application is approved, a grocery gift card will be mailed or emailed to applicant for immediate assistance.
 
If you have any questions or need assistance filling out this form, please call the Western Pennsylvania Bleeding Disorders Foundation at 724-741-6160.
 

Question Title

* 1. Applicant Information

Question Title

* 2. Has there been a significant change in income or a change in the size of your family? If yes, please explain and state when the change took place.

Question Title

* 3. How many adults and children live in the household?

Question Title

* 4. What is the dollar amount of the gift card you are applying for?

Question Title

* 5. Our funds are specifically for people affected by bleeding disorders. Can you tell us how you or your family member's bleeding disorder makes it difficult to access nutritious food?

Question Title

* 6. What bleeding disorder does the affected family member have?

Question Title

* 7. Please provide any additional information to support the reason you are applying for financial assistance for groceries.

Question Title

* 8. WPBDF Emergency Grocery Assistance Fund should be used as a payer of last resort and is not meant to be used to remedy chronic financial problems. Please indicate which resources you have applied for or are currently utilizing. Please select "Other" and use the comment box to provide any additional information that you think would be helpful for us to know. If you haven't applied for other resources, please use the comment box to explain why.  (Select all that apply).

Question Title

* 9. If you have not utilized a food pantry, why not?
(Skip to the next question if you have utilized a food pantry).

Question Title

* 10. If you have utilized a food pantry, please share the name and location of the food pantry you utilize.

WPBDF patient assistance funds are intended to be used to help families manage financial stress due to a bleeding disorder; and therefore, our policy on distributing funds reflects this. We work closely with social workers from the Hemophilia Center of Western PA to ensure these funds are reaching patients in need, as a payer of last resort, and that patients are connected to other local resources and programs, as needed. This is one of the reasons why it is necessary to maintain regular clinic appointments: pediatric patients are typically seen 1-2 times a year, depending on their diagnosis, and adult patients are typically seen once a year or once every other year, depending on their diagnosis.

If you are not current on your clinic appointment and getting to the treatment center is a challenge for you, please know that funds are available to help you/your family members access care. Examples of transportation assistance include taxi fare, bus fare, and gas cards. For assistance with transportation costs, please contact a social worker at the HCWP (412-209-7280). During your appointment, HCWP staff can also help direct you to other specific resources that might benefit you.

Question Title

* 11. Are you/your family member a patient of the Hemophilia Center of Western PA?

0 of 17 answered
 

T