Apply for Assistance Form

Application for Financial Assistance

Physician Information
Physician / Health Care Provider*
Physician / Health Care Provider's Title
Physician's NPI
Please note: This form asks for social security numbers to deter fraud. They are not required. However, they are very helpful.
Child Information
Child's Name
Child's First Name Initial Child's Last Name
Child's Date of Birth
MM
DD
YYYY
Child's Gender
- Male
- Female
Who has legal custody of the child?
Mother's Name
Mother's Social Security # (optional)
Father's Name
Father's Social Security # (optional)
Legal Guardian's Name
Guardian's Social Security # (optional)
Residence
Residence Phone
Residence Address
Street Address Address Line 2 City State ZIP Code
Financial & Family
Total family gross income per year
Total number of family members
Attach most recent Income Statement
Drop files here or
This can be a tax return, W-2 or pay stub. A mobile phone photo is acceptable.
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
Additional Family Member Name
Social Security # (optional)
If more than 10 Family Members, list additional here
Medical Details
Please fill out the fields below to the best of your ability. If necessary your child’s physician can fill in any missing information.
What inborn error of metabolism is present in the child?
What medicines / dietary supplements are being requested for the applicant?
How long will the applicant need to be on the prescribed treatment?
Financial Details
What is the expected total cost per month for prescribed treatment?
How much of this expense will be covered by insurance or State / Federal Assistance?
TOTAL MONTHLY REQUEST FROM THE FOUNDATION:
Signatures
Name
First Last
Email
By signing below electronically, I certify that the above information is true and correct to the best of my knowledge.
Sign below using your mouse or finger on a touch screen device.
- Physician Use Only
- Physician's Name
  First Last
- Physician's Email
- Physician's Phone
- By signing below electronically, I certify that the above information is true and correct to the best of my knowledge.
- Sign below using your mouse or finger on a touch screen device.

Save and Send to My Physician

Mail-in Application

Would you like to print and fill out an application?

You may download this PDF,

and bring the completed application along with a copy of the first page of the family’s most recent IRS Form 1040, (or other form of income verification), to the child’s physician and they will reach out to us on your behalf.

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
1047 Algonquin Road
Norfolk, Virginia 23505

Apply for Assistance Form

Application for Financial Assistance

Physician Information

Child Information

Residence

Financial & Family

Medical Details

Financial Details

Signatures

Physician Use Only