Emergency Support Program Application

Complete the application to determine your eligibility for assistance. To complete the application process, you will need to upload proof of diagnosis and any bills or invoices from vendors that require payment.

You will also need to complete the HIPAA Authorization Form and Vendor Authorization Form. Submit the HIPAA Authorization Form to your healthcare provider and the Vendor Authorization Form to any vendors that require payment. Once the forms have been completed, upload them to the appropriate sections of the application.

To help avoid delays, please have the required documents and vendor information ready before you begin.

First Name

Last Name

Phone

Are you a U.S. Citizen?

Yes

Have you received Emergency Support funds from The Ree Wynn Foundation in the past 12 months?

Yes

Have you been diagnosed with TTP or are you a caretaker of someone diagnosed with TTP?

I have been diagnosed with TTP

I am a caretaker of someone diagnosed with TTP

Applicant doctor/facility name and phone number

Complete if you are applying as the patient.

Patient full name

Patient doctor/facility name and phone number

Complete if you are applying as a caretaker.

If you are human, leave this field blank.