can the OHF help you?

OHF’s Benevolence Program is designed to get emergency resources to those most in need in the bleeding disorders community. In response to the COVID-19 crisis, OHF’s Board has voted to commit additional funds to the Program. We are also reaching out to the industry to request additional assistance.

Please remember that the need is always greater than the available resources. To ensure we get help to those most in need, all OHF assistance will be awarded through the Benevolence Program application below. Click below to download application and release form.

OHF Benevolence Program Application
- HTC Release Form
Scroll down to complete a digital application.

Every donation helps the OHF support families and individuals.

Digital Benevolence Application

Please read the application before you begin. There are requirements that must be completed and questions you will need to prepare to answer before you begin.

You need to contact the 211 hotline for social services (located in the RESOURCES section of the OHF website) prior to submitting this application.
You also need to contact the Oklahoma Center for Bleeding Disorders Social Worker prior to submitting this application to seek assistance of a more permanent nature at 405-271-3361 or 1-800-688-5288. We will follow up with the Social Worker to verify a plan has been made to deal with the reason leading to the need for assistance.
Be prepared to email documents to OHF’s director, Tim Grogan: tgrogan@okbleedingdisorders.org
Be prepared to give authorization to release heath information.

Name

Please list your first, middle, and last name and any other names you use.

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate

YYYY

Phone

(###)

###

####

How much are you requesting and for what purpose? You must send a copy of the bill to TGrogan@okbleedingdisorders.org

What is the date that action must be taken to prevent adverse action? If you have received a suspension of services, eviction, or foreclosure notice, please send a copy to TGrogan@okbleedingdisorders.org

I understand that I must contact the 211 hotline for social services (located in the resources section of the OHF website) prior to submitting this application.

When did you contact 211 social services and what was their response?

I understand that I also need to contact the Oklahoma Center for Bleeding Disorders Social Worker prior to submitting this application to seek assistance of a more permanent nature at 405-271-3361 or 1-800-688-5288. We will follow up with the Social Worker to verify a plan has been made to deal with the reason leading to the need for assistance.

Please verify and e-sign below: I verify the Information Release form from our website so we may contact the social worker and that the above information is correct to the best of my knowledge and that I have not received benevolence funds from OHF in the past 12 months.

First Name

Last Name

Name of Physician, provider, and/or Department / Clinic

By providing this name, you give permission for them to release, verbally, information regarding appointment dates/times and my protected health information checked below that it created or maintained.

First Name

Last Name

I give permission for the for mentioned Physician, Provider, and/or Department / Clinic to release, verbally, information regarding appointment dates/times and my protected health information checked below that it created or maintained.

Entire Health Record

Entire Health Record plus Billing Records / Notes

Psychotherapy Notes*

X-ray Reports / Filma

Immunization records

Discharge Summaries

Medications

Pathology / Lab Reports

Billing Reports

Authorization to Release Protected Health Information for 12 months

• I may revoke this Authorization at any time by providing my written revocation to the clinic named in the upper left-hand corner or the University Privacy Official at University of Oklahoma Health Sciences Center, P.O. Box 26901, Oklahoma City, OK 73129. My revocation will not apply to information already retained, used, or disclosed in response to this Authorization. Unless sooner revoked, the automatic expiration date of this authorization will be 12 months from the date of e-signature. • Unless the purpose of this Authorization is to determine payment of a claim or benefits, OU may not condition the provision of treatment or payment for my care on my signing this Authorization. • For non-students, information used or disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy laws. Student treatment/education records may retain continuing privacy protections in accordance with 34 CFR Part 99 (FERPA). • THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE RECORDS THAT MAY INDICATE THE PRESENCE OF A COMMUNICABLE DISEASE OR NONCOMMUNICABLE DISEASE. • *The information authorized for verbal release may include information related to mental health. Release of mental health records or psychotherapy notes may require consent of the treating provider or a court order. • The information authorized for release may include substance use disorder records. This category of medical information/records is protected by Federal confidentiality rules (42 CFR Part 2). A general authorization for the release of medical or other information is not sufficient for this purpose. As a result, by signing below, I specifically authorize any such records included in my health information to be released. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. The Federal rules prohibit anyone receiving this information or record from making further release unless further release is expressly permitted by the written authorization of the person to whom it pertains or is otherwise permitted by 42 CFR Part 2.