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.
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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?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________