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.

"*" indicates required fields

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

Are you 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 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

Name of person completing request (first, last)*

Relationship to person with MD (select from dropdown)*

Name of person with MD (first, last)*

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

Date of birth (mm/dd/yyyy)*

Email Address*

Phone Number*

Address*

City*

State*

Zip Code*

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

Is the person with MD on any Medicaid Waivers? (select from dropdown)*

Requested item/ service/ project*

How will this item/service impact the life of the person with MD if fully or partially funded?*

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

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

Thank You for completing the form. If you have not heard back from an MDFF represenative within 7 business days, please reach out to info@mdff.org to make sure we have your application in process. Thank you.

Name

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

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