Disaster Assistance Grant Request Form

Through donations made to our Disaster Relief Fund, the American Osteopathic Foundation strives to alleviate some of the financial burdens that result from disasters that impact the towns and communities of our Osteopathic family.

At this time, Disaster Relief grant eligibility is limited to those affected by natural disasters declared by the Federal Emergency Management Agency (FEMA) during the third and fourth quarters of 2024.

These funds were given by AOA/State Association members for members. The AOF has limited Disaster Relief grant dollars available. We will close the application when all funds are expended, but should we receive more requests than dollars available, we will keep the requests on file and fulfill them when/if funds are replenished.

Eligibility

One-time grants in the amounts of $150, $250, or $500 are currently available to practicing Osteopathic Physicians and Osteopathic Residents who are victims of natural disasters and need assistance to restore their medical practice to ensure continuation of care. This program is limited to DOs who have been members of the AOA and/or their Affiliate State Association during the last 18 months. The current medical license number of the Osteopathic physician is required. Grants may be used for expenses not covered by insurance. Eligible individuals must live and/or work in a community affected by a FEMA-declared disaster.

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* 1. Your Information

Name *

Address *

Address 2

City/Town *

State *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. Identify the major disaster declaration area in which you live or practice:

Virginia: DR-4831

North Carolina: DR-4827

South Carolina: DR-4829

Georgia: DR-4830

Florida: DR-4834

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* 3. Amount Requested (up to $500).

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* 4. How will the funding be used? (Should be used to provide direct patient care).

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* 5. Please enter your AOA or State Association membership number.

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* 6. Please enter your medical license number.

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* 7. By submitting this grant request, I attest I meet the following eligibility requirements: I live and/or work in a community affected by a FEMA-declared disaster. I am a DO member of the American Osteopathic Association and/or my Osteopathic State Association. I am fully licensed and still in an active form of practice. I further agree that funding will only be distributed for professional damages (not personal property). The Fund is only for individuals. Funds are will not be distributed to corporate entities, hospital systems, Colleges of Osteopathic Medicine or private practices.

Yes

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* 8. I certify the information provided in this application is accurate and complete to the best of my knowledge. I understand failure to provide full documentation or falsification of credentials could result in disqualification of this application. I agree to provide, if requested, official documentation to verify information reported on this application.

Yes