COVID-19: CF Patient Assistance Program

This program was created to lighten the financial burdens that people with cystic fibrosis are facing due to the COVID-19 pandemic.

Program Guidelines

medical related expenses including but not limited to medications and medication co-pays
insurance

THIS IS NOT A REIMBURSEMENT PROGRAM.

Applicants must complete an official application.
A letter from the patient’s social worker/physician stating:
- the patient has cystic fibrosis,
- how much money is needed,
- and where the funds should be allocated.
- A statement explaining why the patient is in need of funds (i.e. loss of wages, loss of job, etc

*Please specify reasons for relief. The more detail this letter provides, the more attention the evaluation committee will give your application.

*Note – grant payment will be made directly to third parties only in a one time payment. Grant allocation conditions may vary.

**BEF reserves the right to request more documentation.

Please email Chris McEwan (covidrelief@esiason.org) or call 646.292.7939 if you have question about the program or would like to make a donation.

Name*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Birthday*
MM slash DD slash YYYY
Number of people with CF in my household:*
CF Center*
Have you applied for and received other types of relief aid?*
- Yes
- No
How did you hear about our program?*
Have you ever been convicted of a crime?*
- Yes
- No
If yes, please explain.
Additional Documentation
Upload Social Worker/Physician Letter and Invoices*
Drop files here or

Max. file size: 512 MB.
By submitting this application, I certify that the information presented in my application is accurate and complete. I understand and agree that any inaccurate information, misleading information, or omission will be cause for the rescission of any grant offered to me. BEF may verify any and all parts of my application materials.*
I agree to the above stated policy.
CAPTCHA

Please download and complete the application form:

Boomer Esiason Foundation
Attn: Chris McEwan
200 B Armstrong Road
Garden City Park, NY 11040

516.746.4437