Instructions for Applying for Financial Assistance:



PATIENT ASSISTANCE PROGRAM

Transplant Recipient Application

I am a social worker completing a Patient Assistance Program application for a transplant recipient.

Before completing the application, please review application instructions and guidelines.

INSTRUCTIONS

STEP 1: Please review the program’s guidelines and grant categories and then complete this application in its entirety.

STEP 2: Once complete, submit this application for review. This is to ensure your request will be processed in a timely manner, usually within 5 business days.

GUIDELINES

I. Referrals and requests for funding may only be made by social workers at transplant centers designated by the Organ Procurement and Transplantation Network (OPTN.) Patients or individuals/medical professionals seeking assistance on behalf of a patient should contact the patient’s assigned social worker at his/her personal transplant center for details.

II. Staff at the American Transplant Foundation will communicate with the social worker and vendor directly. Patients are strongly discouraged from contacting the Foundation about the status of his or her application.

III. Applications are reviewed on a case-by-case basis. Eligibility for financial assistance is based upon the sole discretion of the American Transplant Foundation and is subject to the availability of funds.

IV. The maximum grant allocation is $500.00 for transplant recipients. The grant request may be a one-time maximum request or multiple partial grant requests totaling the maximum grant allocation. In the event of a partial grant request, the patient may continually apply for grants until the maximum has been reached.

V. All disbursements will be made directly to the vendor, never to the patient.

Assistance to Transplant Recipients

Grants under this category shall be awarded for out-of-pocket expenses related to the following:

I. Delinquent insurance premiums to prevent loss of insurance coverage.

II. Co-payments or medical expenses during insurance gap periods and/or changes in insurance provider.

III. Job placement expenses to aid in obtaining insurance after Medicare ineligibility 3 years after the transplant.

a. Grant requests for job placement expenses must be made within one year of Medicare ineligibility.

b. As it is our goal to achieve measurable, long-term outcomes, we ask that you provide an explanation via email of how this grant will help the patient to bridge the gap and secure long-term insurance coverage.

Additional Information

All grants are made possible through the generosity of the Transplant Leadership Council Members (Young Professionals Organization) and individual donors.

Patient testimonials are critical to the success of this program. If awarded a grant, though not a requirement, we would appreciate a written or video testimonial and a photo of the patient.

Application for Emergency Financial Assistance

Please fill out this form electronically

STEP 1: PATIENT INFORMATION

Patient Name:     

Type of Transplant:      

Date of Transplant:      

Reason for Referral and Amount Requested (please provide a detailed explanation of the patient’s situation):      

Home Address:      

City:       State:       Zip:      

Telephone (Home):       (Cell):      

E-Mail:      

Gender:       Date of Birth:      

Number of Dependents:       Ages:      

Patient’s Employment History

Is the patient currently employed? Yes No

Last or Current Employer:       Last Date of Employment:      

Position Held with Employer:      

Does the patient’s job include considerable physical labor? Yes No

Patient’s Insurance Information

Medicare Yes No

Date of Medicare Eligibility:      

Date of Termination for Medicare Immunosuppressive Therapy:      

Medicaid Yes No

Private Insurance Yes No Name of Insurance Company:      

Patient’s Monthly Insurance Premium:      

Household Revenue and Expenses

Is the patient the head of household? Yes No

Does the patient currently have a savings account? Yes No

Amount Saved: $     

Total Household Monthly Income (after taxes):      

Household Wages contributed by patient:      

Household Wages contributed by other household members:      

Social Security Income:      

Disability Income:      

Mortgage/Rent:      

Total Household Monthly Expenses including housing:      

Monthly Medical Expenses

Monthly Cost of Post-Transplant Medications Covered by Patient:      

Monthly Cost of Post-Transplant Medications Covered by Insurance:      

Doctor Visits:       % Covered by Insurance:      

Other:       % Covered by Insurance:      

STEP 2: VENDOR CONTACT INFORMATION

Company Name:      

Address:      

City:       State:       Zip:      

Client/Account ID:      

Contact Person:      

Contact Phone Number:      

Amount Owed:      

STEP 3: TRANSPLANT CENTER CONTACT INFORMATION

Referred by:      

Social Worker Name:      

Transplant Center:      

Phone:      

Fax:      

Email Address:      

STEP 4: ADDITIONAL QUESTIONS

This grant will make it possible for a patient to bridge the gap while looking for a long-term insurance coverage solution.

Yes No Please explain:      

Is the patient receiving financial assistance from another organization?

Yes No Please indicate the amount and allocation of financial assistance:      

In addition to financial assistance, the patient is interested in talking with a volunteer consultant for free advice in one of the following areas:

Budget Planning

Mortgage Consultation

Resume Review

Nutrition Advice

Assistance from other Non-Profits and Pharmaceutical Companies

Legal Issues Related to Housing

Mentorship from a Transplant Recipient

If awarded a grant, would the patient be willing to provide a written or video testimonial and a photo of himself/herself explaining the impact that the grant had on his/her life?

This would be posted on American Transplant Foundation’s website. If requested, we could omit the patient’s last name.

Yes No

I affirm the information provided to be true and accurate to the best of my knowledge. I understand that all applications are reviewed on a case-by-case basis, and that eligibility for one-time, emergency financial assistance is based upon the sole discretion of the American Transplant Foundation and is subject to the availability of funds. All disbursements will be made directly to the vendor.

Failure to complete this application in its entirety results in automatic denial.

_________________________________________________ __________________

Signature of Patient Date      

_________________________________________________ __________________

Signature of Social Worker Date      

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