Financial Assistance Request Form

If this is your first time accessing our financial assistance program, please see our policy on coverage first.

There is a maximum limit of $1000 in available funding per member with a bleeding disorder per year. Requests for parking must be directed to the HTC, which receives a set amount of funding from Hemophilia Ontario per year to cover these costs.

Hemophilia Ontario does not reimburse expenses that have already been incurred. 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.

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.