Treatment Assistance Program Application

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Comments

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All sections of the application must be complete upon submission. Incomplete applications will not be reviewed. Submission of this application does not guarantee approval. All applications will be reviewed by the NFED Patient Care Council who will make approval decisions. This determination is based on both the treatment plan and available funding. The NFED will contact the applicant in writing to inform them of the application status.

If you have any questions, please direct them to Kristin Matus-Kelso at kristin@nfed.org or 618-566-6388, and she will be happy to assist you.

Before submitting your application, please review our Treatment Assistance Application Instructions for requirements and supplemental materials.

I am applying for:*

Dental Treatment Assistance

Other Treatment Assistance

Genetic Testing Stipend

Patient's Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Some of our applicants may qualify for special genetic testing funding if they meet certain criteria. Are you a woman age 18-40?*

Yes

Prefer not to answer

Patient's Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Phone Type*

Alternate Phone

Phone Type

Email*

Guardian's Name, if applicant is claimed on tax returns

First Last

Guardian's Address, if different than above

Street Address Address Line 2 City State ZIP Code

Please indicate the applicant's adjusted gross income for the person responsible for payment.*

Less than $49,999

$50,000 – $59,999

$60,000 – $74,999

$75,000 or greater

Number of Individuals in the Household*

Please list the names and ages of those in your family affected by ectodermal dysplasias.*

List each member and their age with a comma separating family members, ex: First Last – Age, First Last – Age

Type of Ectodermal Dysplasia (if known)*

Experts have developed a new system to organize the 50+ different types of ectodermal dysplasias. Click here to learn more about the types of ectodermal dysplasias.

Please Specify Type*

Describe the service/treatment for which this application is being submitted.*

In what way do you hope this service/treatment will improve the applicants qualify of life?*

Do you have any other current medical expenses or extenuating circumstances?*

Yes

If yes, please summarize and indicate cost.*

What amount can your family afford to pay toward the total cost of the treatment for which assistance is requested?*

How will you pay the uninsured or unfunded portion of this care?*

In the space below, please provide any other information that may be pertinent to this application.

Please upload 2 recent photographs of the patient, one forward-facing and one profile view, at least 2”x3” in size.*

Drop files here or

Max. file size: 50 MB.

Please upload a letter from the patient’s primary physician (not dentist) listing related symptoms and confirming their diagnosis. Genetic test results accepted.*

Max. file size: 50 MB.

Please upload a quote for your requested product or documentation with estimated treatment cost.*

Max. file size: 50 MB.

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ALL SECTIONS OF THIS APPLICATION MUST BE COMPLETED. INCOMPLETE APLICATIONS WILL NOT BE REVIEWED.*

Check all that apply:

I am willing to participate in public relations activities (photographs or stories) related to the NFED’s Treatment Assistance Program.

I fully understand the treatment plan as submitted by the dental treatment center and have no further questions.

I understand that if my treatment plan changes or if I decide to pursue treatment with a different provider that I will need to submit a new complete application for consideration.

I give permission to allow the NFED staff to contact my care providers (dentists, doctors, patient care staff, etc.) to discuss my or my child’s treatment plan.

ALL SECTIONS OF THIS APPLICATION MUST BE COMPLETED. INCOMPLETE APLICATIONS WILL NOT BE REVIEWED.*

Check all that apply:

I am willing to participate in public relations activities (photographs or stories) related to the NFED’s Treatment Assistance Program.

I give permission to allow the NFED staff to contact my care providers (dentists, doctors, patient care staff, etc.) to discuss my or my child’s treatment plan.

By clicking below, I/We have reviewed the Treatment Assistance Program Application Instructions for additional requirements and supplemental materials.*

Click here to review the Treatment Assistance Program Application Instructions

I agree

By clicking below, I/We hereby confirm that the information provided herein is accurate, correct and complete and that the documents submitted along with this application form are genuine.*

Once you submit this form, you should receive a confirmation email at the address provided in the form. Be sure to check your inbox for additional instructions to complete your application.

I agree