You can either fill out our digital application, or download the PDF version. If you choose to download the application, once you complete it you can either send it to us via mail to the foundation PO Box (PO Box 1490, Buffalo, NY 14215) or email it to us (

Click the button below to download the application.

Download Application

Application for Assistance

  • Referral Agency Information

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  • Patient Information

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  • Parental Information

  • Drop files here or
    Max. file size: 32 MB.
      If you do not have a digital version of the bills feel free to mail / hand deliver them to us.
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