NKF Helps Hurricane Residents Get Back On Track

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NKF Helps Hurricane Residents Get Back On Track

NKF Offers Assistance for Flood VictimsRecent major hurricanes have devastated parts of the United States, leaving many patients with limited or no access to necessary medication and treatment. NKF can help. If you have kidney disease and were affected by the hurricanes, please ask your dialysis unit or transplant center social worker to contact NKF to find out if you are eligible for assistance. You can download the Financial Assistance Grant Application for those affected by the storms here www.kidney.org/news/pdf/FinancialASSTApp3-07.pdf see below (new post)

In addition, the Centers for Medicare & Medicaid Services will provide up to $2 million to help uninsured hurricane victims in Texas obtain a one-time, 30-day supply of medication or certain durable medical equipment. For more information on the Emergency Prescription Assistance Program (EPAP) Ike Activation, click http://www.disasterhelp.gov/start.shtm

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Below is a cache of http://www.kidney.org/news/pdf/FinancialASSTApp3-07.pdf. It's a snapshot of the page. The direct link appears to have been corrupted and I have reported it to NKF.
"Reported Attack Site:   (from Google)     
This web site at www.kidney.org has been reported as an attack site and has been blocked based on your security preferences.
Attack sites try to install programs that steal private information, use your computer to attack others, or damage your system.
Some attack sites intentionally distribute harmful software, but many are compromised without the knowledge or permission of their owners."

Office Use Only
Denied
Approved
Amt: $________ Date: ________
By: _____________

FINANCIAL ASSISTANCE GRANT APPLICATION
Section A (To be completed by patient)

Date: _________________

_________________________________________________________________________
Name
Telephone
_________________________________________________________________________
Home Address
_________________________________________________________________________
City
State
Zip Code

_________________________________________________________________________
Date of Birth
Gender: M F
Social Security #

_ __________________________________________________________
# of dependents
If minor, name of parent

Medical Insurance Carrier: ____________________________________________________

Amount Requested: $_________________ Reason for Request: _____________________

_________________________________________________________________________

_________________________________________________________________________
List income from all household members plus any additional sources.

Monthly Household
Expenses

Rent/Mortgage $_________

Utilities $______________

Actual Payment on Medical
Bills $_____________

Other $_____________
$

$_____________

TOTAL $_____________
Monthly Household
Income

Salary $__________
(take home)

Social Security$________

Public Assistance $________

Pension
$___________
Child Support/
Alimony
$____________
Other $_______________

Income/Assets
Checking $_________

Savings/CD $_______

Home $________
(assessed value)

Auto $____________
__________________
Year/Make/Model
Retirement $_________
Stock/Bonds $________
I certify that the information above is correct to the fullest extent of my knowledge
and that all possible alternative sources of funding have been explored.

Signature of Applicant: ___________________________________ Date: _______________


........................................................................................

Office Use Only
Denied
Approved
Amt: $________ Date: ________
By: _____________

FINANCIAL ASSISTANCE GRANT APPLICATION
Section B (To be completed by social worker)

____________________________________________________________________________
Patient Name
Date
____________________________________________________________________________
Social Worker’s Name
Telephone
____________________________________________________________________________
Agency/Facility
____________________________________________________________________________
Address
____________________________________________________________________________
City
State
Zip
____________________________________________________________________________
Email Address
Pager
Have funds been sought from the following sources?

Medicare
Yes No
Explain/Benefits ____________________

Medicaid
Yes No
Explain/Benefits ____________________

Vocational Rehabilitation
Yes No
Explain/Benefits ____________________

State Renal Program
Yes No
Explain/Benefits ____________________

Health Insurance Coverage
Yes No
Explain/Benefits ____________________

Have other avenues of relief been exhausted (relatives, dialysis unit funds, government or other
agencies?)
Yes
No

Has patient been awarded a Financial Assistance Grant in the past? Yes No
When? ______________ How much? $_____________
Describe the purpose of this grant request. In your comments, justify the amount requested.
Explain how this grant will remedy the situation in the near future, and how the will patient
address or avoid a similar financial need in the future?
___________________________________________________________________________

___________________________________________________________________________

_________________________________________________________________________

I certify that the information above is correct to the fullest extent of my knowledge and that all
possible alternative sources of funding have been explored.

Social Worker’s Signature: ________________________________ Date: _______________
Return completed form to the National Kidney Foundation
Sheila Weiner, Patient Services Director – Fax: 212-689-9261, Phone: 212-889-2210 ext. 198
30 East 33
rd
Street, New York, NY 10016
Have funds been sought from the following sources?

Medicare
Yes No
Explain/Benefits ____________________

Medicaid
Yes No
Explain/Benefits ____________________

Vocational Rehabilitation
Yes No
Explain/Benefits ____________________

State Renal Program
Yes No
Explain/Benefits ____________________

Health Insurance Coverage
Yes No
Explain/Benefits ____________________

Have other avenues of relief been exhausted (relatives, dialysis unit funds, government or other
agencies?)
Yes
No

Has patient been awarded a Financial Assistance Grant in the past? Yes No
When? ______________ How much? $_____________
Describe the purpose of this grant request. In your comments, justify the amount requested.
Explain how this grant will remedy the situation in the near future, and how the will patient
address or avoid a similar financial need in the future?
___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________