Financial Assistance Request

If this is your first time accessing our financial assistance program, please see our list of covered items & policy first.

There is a maximum limit of $1000 in available funding per member with a bleeding disorder per year.

Hemophilia Ontario does not reimburse expenses that have already been incurred without approval first. Incurred expenses will be reviewed on a case-by-case basis. Applicants may also be requested for proof they have sought and been denied funding from other sources first.

Please reach out to Sarah Levy ( SLevy@hemophilia.on.ca ) for Financial Assistance.

Financial Assistance Request Form

If members encounter technological difficulty of any kind, or prefer to mail in their request, they can alternatively access a PDF version of the Financial Assistance Request form here

Applicant Name: (required)

Street Address: (required)

City: (required)

Postal Code: (required)

Primary Phone Number:

Secondary Phone Number:

Your Email (required)

I prefer to be contacted by
EmailPhonePost Mail

Hemophilia Treatment Centre
St.Michael’s HospitalSickKids HospitalLondon Health Sciences CentreHamilton Health Sciences CorporationThunder Bay Regional Health Sciences CentreHealth Sciences North (Sudbury)Kingston General HospitalThe Ottawa HospitalChildren’s Hospital of Eastern Ontario (CHEO)

Amount Requested

Details of Request

Do you give permission for Hemophilia Ontario to contact your clinic team for more information, if required?
YesNo
Applications will still be considered where permission is denied, though may be declined if there is insufficient evidence of the direct connection to bleeding disorder care.

A signature is not required for online applications. By electing to submit your completed application, you are attesting to the accuracy of the information submitted and understand that funding decisions are final.