Patient Assistance Fund - Request Form

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The BMT InfoNet Patient Assistant Fund (PAF) assists patients and caregivers with living expenses during treatment.

Grants are $100-$300. We cannot accommodate larger grant requests.

Who is eligible for Assistance

  • Patients who had an autologous transplant or an allogeneic transplant with a related donor within the last 12 months
  • Allogeneic transplant patients, regardless of donor type, who are 12-24 months post-transplant and are receiving ongoing medical care for chronic graft-versus-host disease
  • Patients who have not previously received a grant from BMT InfoNet’s Patient Assistance Fund
  • Patients who have undergone CAR-T therapy within the last 12 months

Expenses We Cover While Patient is Undergoing Treatment:

  • Transportation to and from medical care
  • Food
  • Lodging
  • Utilities

Expenses We Do NOT Cover:

  • Medical bills
  • Medications
  • Insurance co-pays

Application Process:

  • Application for funds must be completed by a social worker or transplant center personnel who certifies that the patient is in need of financial help
  • Please wait until day one of transplant prior to submitting application
  • ALL sections of the application form must be completed in order to be considered
  • If you have questions, please call 888-597-7674

Evaluation/Decision/Disbursement of Funds

  • Patient and Transplant personnel will be notified via email or mail when application is received.
  • Fully completed applications will be reviewed within two weeks of receipt. Incomplete applications will delay review.
  • Applicants and transplant personnel will be notified of the decision following review.

Please complete the following application with as much detail as possible with the patient/caregiver. Failure to complete the application in full will result in delay of review and funding.

Adult requesting Funds
This area is to be used for Patient/Adult Requesting Funds.

If the person who is requesting the funds is not the patient.  Please provide the following:

Type in disease to see list or select Other and complete the diagnosis description.
If you did not see your Diagnosis on the drop down list or have additional information on the disease, please provide this information.
Please wait until day one of transplant prior to submitting application
If yes, Describe the type and extent of GvHD
Grant
Indicate name and relationship of all people in household and any additional people who will utilize the funds.
Include patient's current medical, living, family and financial situation. Please send additional information by email to amy@bmtinfonet.org or fax to 847-433-4599.
Please include income of ALL members of the household. Include the amount of: Wages, Investment income, SSI, Disability payments, etc.
$
If requesting payment to another party, such as a landlord or utility company, complete the following: • Name of party to whom payment should be sent • Account number on bill, if applicable • Address • City, state zip

If the applicant is requesting the gift card to be sent to a different address than the home address, please provide the full address below. 

+4 digits of Zip Code
Transplant Center Staff Person Contact Information and Verification
I affirm that the information provided in this application is true and complete, and I am recommending this patient for financial assistance.