PAG Application

The DSF Patient Assistance Grant Program offers grants to patients for necessary medical equipment, therapy devices, and educational aids not covered by insurance or assistance programs.

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)

First Last

Are you a member of the DSF Family Network?(Required)

Yes

Unsure

Have you previously applied to DSF's PAG program?(Required)

Yes

Unsure

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Patient Name(Required)

Date(Required)

Gender(Required)

Male

Female

Child's Diagnosis(Required)

(include primary and secondary, if applicable)

Equipment Requested(Required)

(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.)

Estimated Cost(Required)

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

Single PDF containing all supporting documentation (optional)

Max. file size: 128 MB.

Physician Letter(Required)

Max. file size: 128 MB.

Proof of Income(Required)

Max. file size: 128 MB.

Insurance Denial Letter

Max. file size: 128 MB.

Application for Medical Professionals

The application is for medical professionals or social workers submitting on behalf of a patient. The 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. The request must be on the physician’s letterhead and list the patient’s diagnosis.
A letter of denial from the insurance provider stating that the requested equipment and/or service was denied, if applicable. Not required for cooling vest, iPad, or seizure monitors (excluding Embrace2).
Any other documentation pertaining to the nature of your request. All information is kept confidential.

Submitter Information
Name of Person Submitting Application*
First Last Suffix
Institution/Business*
Title/Position*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Patient Information
Parent/Legal Guardian Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Has the parent/legal guardian ever submitted an application to DSF's PAG program previously?*
- Yes
- No
- Unsure
Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Patient Gender*
- Male
- Female
Patient's Diagnosis*
(include primary and secondary, if applicable)
Equipment Requested*
(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.)
Estimated Cost*
Please research the cost of any item(s) before submitting the 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
Single PDF containing all supporting documentation (optional)
Max. file size: 128 MB.
Physician Letter*
Max. file size: 128 MB.
Insurance Denial Letter
If applicable. Not required for cooling vest, iPad, or seizure monitors (exlcuding Embrace2).
Max. file size: 128 MB.
Other Documentation
Max. file size: 128 MB.
Confirmation Checkbox*
- I acknowledge that the I have discussed the application with the parent/legal guardian named above. The parent/legal guardian has researched the equipment requested. The parent/legal guardian understands that once any items are approved and ordered, they cannot be returned or exchanged for a different item.
Signature*
Name
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.

PAG Application

APPLICATIONS SUBMITTED PRIOR TO MARCH 1 WILL BE REJECTED

Application for Caregivers

Application for HCPs

Application for Caregivers

Application for Medical Professionals

Submitter Information

Patient Information

Dravet Syndrome Foundation, Inc

Dravet Syndrome

Caregivers

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