Financial Assistance - Many Faces of Moebius Syndrome

The Many Faces of Moebius Syndrome is 100% committed to providing financial assistance towards the medical needs of individuals with Moebius Syndrome.

Each fiscal quarter (Q1 2023: January 1 – March 31, Q2 2023: April 1 – June 30, Q3 2023: July 1 – September 30, Q4 2023: October 1 _ December 31, 2023) we will allocate $250 to cover the cost of your uninsured medical needs on items like eye-ointment, special feeding bottles, and special positioning chairs, etc. Totaling $1000.00 a year in payouts.

At the end of each quarter, we will review all applications and approve those with the greatest need. If approved the MFOMS will pay the company supplying the item directly on your behalf. No payments will be made to the applicant.

If you are not approved for assistance, you are welcome to reapply the following quarter. Applications will not roll over. Applications need to be resubmitted each quarter.

To apply fill out the contact form below and we will send you an application.

If you have any questions, please email us at admin@mfoms.org.

Thank you.

Team MFOMS

Finacial Aid Form for medical supplies

Date / Time

Date

Time

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Present Occupation / Place of Employment

Name of person with Moebius Syndrome who the financial aid is for if different from applicant?

Age of individual?

Medical Item which is no longer covered by insurance? / Costs

Name of company providing item?

If you live outside the United States please enter your addresss below.

Is there anything else you would like us to know?

Signature