Financial Assistance Application

How can MDFF help your family?

MDFF will assist with equipment, item or service that promotes quality of life, independence, mobility, or safe living.

While advancements and treatments provide hope, our immediate goal is to provide families with equipment and services to help reduce or eliminate some of the day-to-day challenges that go with living with neuromuscular diseases.

To apply for Financial Assistance:

Step 1: The applicant must be a resident of Indiana and diagnosed with a neuromuscular disease or MD listed on the MDA website here.

Step 2: Enroll with MDFF here.

Step 3: Click here to read the full MDFF Agreement & Waiver.

Step 4: Complete the form to the right.

Note: Most requests that are funded will not exceed $10,000 in assistance provided.

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

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.)

Agree

Is the applicant 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.

Yes

Is the appicant/person with MD enrolled with MDFF?*

Enrollment is required to receive services. If you are not yet enrolled, please do so first here: www.mdff.org/enrollmdff

Yes

Primary Contact Name (First/Last)*

Primary contact will be the person who receives all communications regarding this application and other information as needed. This can be the Enrollee or someone else such as parent/spouse/caregiver/relative if enrollee is a minor or otherwise unable to receive communications.

Relationship of Primary Contact to Enrollee (person with MD)*

Enrollee Name (First, Last) - person with MD*

Enrollee: Date of birth (mm/dd/yyyy)*

Neuromuscular Disease (The applicant must be diagnosed with muscular dystrophy or a neuromuscular disease)*

Proof of Diagnosis: Attach a physician letter on hospital letterhead, genetic testing results, or a medical document listing applicant identifiers and neuromuscular diagnosis*

Max. file size: 50 MB.

Email Address - primary contact*

Phone Number - primary contact*

Address - enrollee*

City*

State*

Zip Code*

Type of insurance of the Enrollee: (note: We are unable to reimburse for items for which payment has already been made.)*

Is the Enrollee on any Medicaid Waivers? (select from dropdown)*

What other funding sources do you have?

We are seeing an increase in the dollar amount of contractor work. MDFF has a limited budget and for high dollar request items it is unlikely our organization can fund the entire proposal.

Requested item/service/project*

How will this item/service impact the life of the Enrollee, if fully or partially funded?*

Upload photos of the need

i.e. the bathroom shower that is not currently accessible, etc. NOTE: some requests, like a wheelchair seat elevator will not need a photo attached

Drop files here or

Max. file size: 50 MB, Max. files: 6.

What are the dimensions of the space? Have you taken measurements yourself to determine the needed work to be done?

This is applicable if the request is for a home modification. (I.e. is the proposed contractor upgrade going to work with your existing space? Or, if there is a moveable item like a portable ramp, is the caregiver able to lift that?). Also, if you have a HOA, you'll need to make sure your request is permitted.

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

I authorize MDFF to use & share information I have provided (type name below)*

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