PATIENT ASSISTANCE PROGRAM

Potential Living Organ Donor Application

I am a social worker completing a Patient Assistance Program application for financial assistance for a potential living donor.

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

INSTRUCTIONS

STEP 1: Please review the program’s guidelines and grant categories and thencomplete this application inits 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

  1. 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.
  1. 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.
  1. 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.
  1. The maximum grant allocation is $1,000.00 for living donors. 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.
  1. All disbursements will be madedirectly to the vendor, never to the patient.

Assistance to Living Organ Donors

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

  1. Loss of wages during the hospital stay and/or recovery due to organ donation.
  2. Grant requests must be received prior to organ donation and, if approved, will be funded on the day of the organ donation.
  3. Grants can be used to cover living expenses, including rent/mortgage. All disbursements will be made directly to the vendor/landlord/mortgage company.
  4. Please explainvia email how this grant will help a particular candidate to make a decision to donate.
  1. Unanticipated medical complications as a result of organ donation. Grant requestsmust be made within 30 days of the surgery.

*Maximum grant allotments for living donors increased from $500 to $1,000, effective December 2012.

Additional Information

All grants are made possible throughthe 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:

Relationship between living donor and recipient:

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 patientcurrentlyemployed? Yes No

Last or Current Employer: Last Date of Employment:

How much paid time off the patient will have following the surgery?

Position Held with Employer:

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

Estimated amount of time off needed after the surgery?

Patient’s Insurance Information

Medicare Yes No

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 have a savings account?Yes No Amount Saved: $

Total Household Monthly Income (after taxes):

Household Wages Contributed by Patient:

Household Wages Contributed by Others:

Social Security Income:

Disability Income:
Mortgage/Rent:

Total Household Monthly Expenses including housing:

STEP 2: VENDOR CONTACT INFORMATION

Company Name:

Address:

City: State: Zip:

Client/Account ID:

Payment Amount Requested:

Contact Person:

Contact Phone Number:

STEP 3: TRANSPLANTCENTER CONTACT INFORMATION

Referred by:

Social Worker Name:

TransplantCenter:

Phone:

Fax:

Email Address:

STEP 4: ADDITIONAL QUESTIONS

This grant will make it possible for a patient to donate an organ.

Yes No Please explain:

On a scale of 1 to 10, how influential will this financial assistance be in the patient’s decision to donate?

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 Living Organ Donor

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 theAmerican 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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Questions? Please contact American Transplant Foundation.

Phone: 303.757.0959 | Fax: 303.757.2990 | Email: