Mail-in Application
Foundation Assistance Request (PDF) Please save this file to your computer and send the completed file to your child’s physician.
The ACIEM Foundation does not accept applications directly from applicants. This application must be submitted by the applicant’s physician’s office or health care agency, (hospital, nurse, registered dietician, genetic counselor, etc.), on behalf of the applicant.
Your child’s physician or health care provider may e-mail the completed application to: baglio@ACIEMFoundation.org or be printed and surface-mailed to:
The ACIEM Foundation
5939 Bellaire Drive
Benbrook, TX 76132
