Direct Family Assistance Program

The Direct Family Assistance Program provides financial assistance for expenses related to a child’s serious medical condition. This can include reimbursement of travel costs for medical care away from home, medical bills, prescriptions, copays and medically-necessary equipment not covered by insurance. This program assists children through age 18 (or 21 for dependents and students) who reside in Jefferson, Lewis or St. Lawrence County.

Your Name

First Last

Phone

Child's age

Under age 19

Dependent or Student over the age of 19 and under age 22

Child's home county

Jefferson

Lewis

St. Lawrence

Please share the child's primary medical diagnosis

With which of the following would the child need assistance at this time? (check all that apply)

Travel reimbursement for medical treatment away from home

Out-of-pocket expenses for medical bills, copays, prescriptions or healthcare supplies not covered by insurance

Medically-necessary equipment not covered by insurance

Other Details (list below)

Other Details

Disclaimer

Do not use this form for medical emergencies. If you are experiencing an emergency, please go to the nearest EMERGENCY DEPARTMENT, or contact Emergency Response Services by dialing 911.

Number