Treatment Assistance Program Application

All sections of the application must be complete upon submission. Incomplete applications will not be reviewed. Submission of this application does not guarantee approval. All applications will be reviewed by the NFED Patient Care Council who will make approval decisions. This determination is based on both the treatment plan and available funding. The NFED will contact the applicant in writing to inform them of the application status.

If you have any questions, please direct them to Kelley Atchison at 618-566-6873 or kelley@nfed.org, and she will be happy to assist you.

The Mary K Richter Treatment Assistance Program

Treatment Assistance Application Instructions

Needed Materials

Any individual applying for funding through the Treatment Assistance Program must provide the following:

• Completed application form
• Two recent photographs of the affected individual at least 2”x3” in size: one forward facing portrait (front view) and one profile (side view).
• Provide a letter from the applicant’s primary physician (not dentist) confirming the diagnosis. This letter must be written on official letterhead, signed by the physician and document the ectodermal dysplasia clinical manifestations that the affected individual demonstrates (e.g., hair, teeth, sweat, nails, or any other). Genetic testing reports will also be accepted.
• For cooling products ONLY: include why the patient is at risk for overheating and a cooling product is medically necessary.
• Quotes of the desired window air conditioning unit, cooling vest, or wig, if applicable.
• Be a registered NFED member. If you are not already, you can register your family at nfed.org/join-us/.    

Any individual applying for funding through the Treatment Assistance Program for dental care must have the dentist(s) responsible for the treatment complete and submit all of the following to the NFED office:

• Completed Care Provider Statement Form (download form).
• A statement from the attending dentist making sure missing teeth are identified (view sample statement).
• A detailed narrative of the treatment plan outlining all treatments, anticipated time frames, and cost of each treatment. If the care includes extractions, implants, crowns, or other tooth specific treatment, please indicate which tooth is involved (view sample treatment plan).
• Completed W-9 (download form).

We’ve prepared a letter you can provide to your dentist/care provider outlining the needed documentation. You can send completed documentation to the NFED office or email it to Kelley at Kelley@nfed.org.