Applying for Financial Assistance
through
Helping AMC Families Incorporated

Who can apply?
Individuals who have been diagnosed with Arthrogryposis or the parent/guardian of an individual diagnosed with Arthrogryposis.


How often can I receive assistance?
Applicants awarded financial assistance will receive $5000 (USD) per year which can be used towards requested assistance and needs approved by Helping AMC Families Incorporated. The award does not have to be spent on a single request and the use of any remaining balance can be requested by submitting subsequent applications for up to one year from the month of the first award. Most awards will be paid directly to the supplier(s), rather than via reimbursement or distributed funds. Any awards granted through reimbursement will require submission of itemized receipts. Any remaining balance left in the anniversary month of the award will be returned to the general pool of funds, to be re-distributed to other AMC families as needed.


What types of assistance are available?
Helping AMC Families Incorporated will assist with expenses directly related to the care and maintenance of the individual affected by Arthrogryposis. If you have a need that is not already listed here, please feel free to apply and describe your request as this is not an exhaustive list of items we are able to help with.

Medical expenses related to the
care/treatment of Arthrogryposis  
Insurance premiums
Copays
Coinsurances
Out-of-pocket expenses
Medical equipment
Adaptive clothing
Orthotics
Orthotic accessories
Medical supplies
Medical equipment 

Medical travel expenses related to
consults/appointments/surgeries
Airline tickets
Mileage
Ground transportation
Parking expenses
Lodging expenses
Meals
Groceries
Tolls 

Other expenses related to
accomodations/quality of life     
Home improvements
Vehicle adaptations
Vehicle accessibility

How long does it take to receive a determination?
We understand that needs can be critical and that the outcome of this application can have an impact on scheduling and planning for important medical care. For that reason, if you require assistance of a more immediate nature we highly recommend seeking out financial assistance that is geared towards emergency funding. While we will do our very best to process all applications as they come in and as quickly as possible, we cannot guarantee a response to an application within a certain length of time. Additionally, applications may be held for a period of time for various reasons and may be approved for months in the future (with the applicant story and funding earmarked months ahead of time) and this requires careful planning on our end to ensure each approved applicant receives the same quality level of attention and care by our organization. We will do our very best to keep you updated!


What is expected of me?
A complete picture of what you are asking for by filling out the application in full and truthfully, including all details, supporting documentation, and information necessary for us to make a decision. Once approved we will need to obtain from you a written bio and information about your journey with AMC and your needs, as well as photos/videos/supporting materials to build a story page for you on the helpingamcfamiles.org website. After approval and posting of your story, we require follow up communication to report any changes or additional approvals from other organizations, a follow up story once the request has been completed, and any receipts or additional supporting materials required to document your award.

AUTHORIZATION TO RELEASE INFORMATION

_{By signing below, I hereby authorize the use or disclosure of any provided health or personal information to any board member, employee, contractor, or other professional retained by, or working with, Helping AMC Families Incorporated (the “HAMCF”). I certify that I am either (a) an applicant seeking assistance from Helping AMC Families Incorporated or (b) have the legal power and authority to release such health and personal information on behalf of the applicant. Further, I certify that I am mentally competent to make medical and/or financial decisions for the applicant. I understand that the information in the applicant’s/my health record may include information related to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. I understand that I/the applicant have the right to revoke this authorization at any time. I understand that if I/the applicant revoke this authorization I/the applicant must do so in writing and recover and destroy all copies of this document that I/the applicant have previously distributed. I understand the revocation will not apply to information that has already been released in response to this authorization.}

<sub>I understand that authorizing the disclosure of this health, financial, or other related information is voluntary. I can refuse to agree to this authorization. I understand I/the applicant may inspect or copy the information to be used or disclosed, as provided in CFR 164.524.

I understand that HAMCF has sole discretion in determining whether to grant me any assistance and that, by submitting this application or seeking assistance from HAMCF, HAMCF does not in any way guarantee, agree, contract, or promise to me that I will be offered or receive any assistance of any kind from HAMCF.

I grant Helping AMC Families Incorporated the right, in their sole discretion, to use, copy, reproduce, publish, distribute, publicly display, or otherwise make sure of my name, image, and likeness, in any and all media now known or hereafter devised, including but not limited to print, online, digital, video, social media, and in connection with all websites or services offered by Helping AMC Families Incorporated, from this date and continuing forever, without any compensation to me. I waive any and all claims, actions, causes of action, suits, or damaged related to rights of privacy, rights of publicity, copyright, trademark, or other personal, intellectual property, or moral rights arising out of or in connection with the use of my name, image, or likeness by Helping AMC Families Incorporated.</sub>

<sub>I release, indemnify, and forever hold harmless Helping AMC Families Incorporated and their respective officers, directors, agents, members, representatives, employees, and volunteers from and against any claims, liabilities, judgements, damages, actions or cause of action, including but not limited to, personal injury, death, or damage to or loss of properly, relating to or arising out of my submission of my application, decisions made of discretion exercised by the charity, including but not limited to, the offering or not offering to me of the assistance requested by my application or any other assistance, and the manner in and means by which any assistance to which I am offered or granted is administered by the Helping AMC Families Incorporated.

Lastly, I hereby permit Helping AMC Families Incorporated to use and retain the health, financial, personal, or other related information provided to Helping AMC Families Incorporated in Helping AMC Families Incorporated sole and absolute discretion. I give Helping AMC Families Incorporated authorization to speak with any other AMC/medical travel assistance programs.</sub>