Application for Financial Assistance

The ELC Foundation is a 501 (c) (3) non-profit corporation founded to meet the needs of patients with multiple sclerosis, their families and caregivers. The Financial Assistance Program assists in funding expenses for patients with multiple sclerosis that are not covered by insurance.

When possible, funds are paid directly to the vendor. This application should be submitted and reviewed BEFORE paying for the item or service.

Demographic Information

Date of Birth(Required)

Request Details

List other resources you have contacted and the amount received, if any
Amount Received ($)
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Patient Verification & Release

The information submitted with this application is correct to the best of my knowledge. I understand The ELC Foundation will review this application, and I fully and knowingly waive and release The ELC Foundation, and its employees, representatives, advisors, partners, directors and agents, from any claims or liability associated, in any way, with the application process, the review of my application materials, or the award of financial assistance. I understand this application does not guarantee financial assistance.
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