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The DSF Patient Assistance Grant Program offers grants to patients with Dravet syndrome and related epilepsies for necessary medical equipment, therapy devices, and educational aids associated with these conditions that are not covered through private insurance or other assistance programs. This program is open to all patients worldwide who are members of the DSF Family Network. The program closes each year on December 1st or once funds are depleted. Any remaining funds are rolled over, with the program opening each year on March 1st.

APPLICATIONS SUBMITTED PRIOR TO MARCH 1 WILL BE REJECTED
Application for Caregivers
Application for HCPs

Application for Caregivers

Your application packet should include the following documentation:

  • Completed application
  • A recent letter from the child’s physician or health care professional explaining the medical necessity of your request
  • A letter of denial from the insurance provider stating that the requested equipment and/or service was denied (when possible)
  • Proof of all income (including your most recent W2 form)
  • Any other documentation pertaining to the nature of your request All information is kept confidential.

Name(Required)
Are you a member of the DSF Family Network?(Required)
Have you previously applied to DSF's PAG program?(Required)
Address(Required)
MM slash DD slash YYYY
Gender(Required)
(include primary and secondary, if applicable)
(Provide exact name of equipment/service; name of manufacturer or provider; and the name and contact information for the vendor. If available, please attach brochure and/or photos. If you are requesting more than 3 items, please contact Jamie prior to submission.)
Please research the cost of your item(s) before submitting your application. An estimated cost must be entered, or your application will be rejected.
Please enter a number greater than or equal to 1.
Hidden
Single PDF containing all supporting documentation (optional)
Max. file size: 128 MB.
Max. file size: 128 MB.
Max. file size: 128 MB.
Max. file size: 128 MB.
Max. file size: 128 MB.
Confirmation Checkbox(Required)
This field is for validation purposes and should be left unchanged.

The information collected by Dravet Syndrome Foundation will not be sold or distributed outside of DSF and is used solely to verify identity and assist with communication. Questions or concerns can be directed to our team

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