Asthma & Allergy Foundation of America

Maryland Chapter

Chester Building, Suite 321 · 8600 LaSalle Road · Towson,MD
Phone (410) 321-4710 · Fax (410) 321-0137

PATIENT ASSISTANCE

The Patient Assistance Program of the Asthma and AllergyFoundation, Maryland Chapter, provides limited funds for unusual or unexpectedexpenses directly related to the patient’s asthma or allergic condition.Generally, services rendered under this program are for “one time only”.
To apply, this form should be filled out completely and must be signedby the patient’s physician or social worker. A committee of AAFA-MarylandChapter will make a decision as promptly as possible and notify the patientor health care professionals.

Date:
Patient’s Name:
Parent’s/Guardian’s Name:
S.S. Number:
Date of Birth:
Address:
City/State/Zip:
Phone: Home/Work
Annual Income:
State specific request:
How will this help you?
Brief medical history:
Other action to obtain aid:
I grant release of medical records to AAFA-MD. Patient’s (parent’s/guardian’s) signature
Physician’s Name:
Phone:
Address:
City/State/Zip:
Social Worker’s Name:
Phone:
Address:
City/State/Zip:
I certify that the information above is correct to the fullest extent of my knowledge, that the above problem is within the scope of the Foundation’s assistance program, and that all possible alternative sources of funding have been explored.
Physician’s or Social Worker’s Signature