Financial Assistance Application

Release Form 

By clicking this box I certify that I have read and fully understand the MDFF Agreement & Waiver in case I am granted full or partial funding for a piece of equipment or home modification. (The document is on this webpage in the paragraph section.)

AgreePlease enter the Release Form.

Are you a resident of Indiana? 

If you are not a resident of Indiana, please do not complete a form. Our organization only serves residents of Indiana.

YesPlease enter the Are you a resident of Indiana?.

Name of person completing request (first, last)  Please enter the Name of person completing request (first, last).

Relationship to person with MD (select from dropdown) 

Self Mother Father Spouse Sibling Doctor Case Worker Other

Please enter the Relationship to person with MD (select from dropdown).

Name of person with MD (first, last)  Please enter the Name of person with MD (first, last).

Neuromuscular Disease (The applicant must be diagnosed with muscular dystrophy or a neuromuscular disease (see applicable diseases listed on the MDA website)  Please enter the Neuromuscular Disease (The applicant must be diagnosed with muscular dystrophy or a neuromuscular disease (see applicable diseases listed on the MDA website).

Date of birth (mm/dd/yyyy)  Please enter the Date of birth (mm/dd/yyyy).

Email Address  Please enter the Email Address.

Phone Number  Please enter the Phone Number.

Address  Please enter the Address.

City  Please enter the City.

State  Please enter the State.

Zip Code  Please enter the Zip Code.

Type of insurance of the person with MD  Please enter the Type of insurance of the person with MD.

Is the person with MD on any Medicaid Waivers? (select from dropdown) 

Family Supports Waiver Aged & Disabled Waiver I don't know No

Please enter the Is the person with MD on any Medicaid Waivers? (select from dropdown).

Requested item/ service/ project  Please enter the Requested item/ service/ project.

How will this item/service impact your life if fully or partially funded?

How did you learn about MDFF? (select from dropdown) 

Medical Professional (doctor, nurse, therapist) Family/ Friend Case Manager Another Organization Internet Search Other

Please enter the How did you learn about MDFF? (select from dropdown).

I authorize MDFF to use & share information I have provided (type name below)  Please enter the I authorize MDFF to use & share information I have provided (type name below).

 

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