2024 Nutritional Supplement Grant Program (Kidney Foundation of Summit County)

Overview

The program provides financial aid to help individuals purchase nutritional supplements through an approved provider, Mobile Meals, Inc.
The social worker/dietitian must complete the application for the patient. The patient must give the healthcare professional authority to sign the privacy practices page and release of information to allow the Kidney Foundation of Summit County to coordinate delivery of service with Mobile Meals, Inc.
The Kidney Foundation of Summit County will review application and notify social worker/dietitian of the status of the application via email.
Applications are considered on an individual basis. Special consideration is given to those patients who are 300% or below of the Federal Poverty Level.
The grant allots $65.00 per month towards purchase of nutritional supplements. Example: patient is approved for the grant beginning in August and lasting through December, $325 will be set aside by the Foundation for the supplement. Funds may be used until depleted. Additional funds will not be authorized once full approved amount has been utilized.
If approved, the social worker/dietitian will fax the Mobile Meals referral form and letter of grant approval to Mobile Meals to initiate services.
Only the supplements currently available through Mobile Meals, Inc. are part of the grant program.
The Kidney Foundation of Summit County’s ability to assist patients is based on the availability of funds. An application for assistance is not a guarantee of acceptance or “entitlement” to services. If funding is not available, the social worker and dietitian will be given a thirty-day (30) notice to alert the patient.
The grant expires December 31, 2024.
A new patient assistance application must be completed annually without exception.
Intentionally misleading information on the application, or misuse/selling of supplements is cause for denial of assistance.

For questions, contact Carolyn Henretta at (330) 864-1236 or carolynruns@yahoo.com.

Patient Information

Patient First Name *

Patient Last Name *

If a minor, name of parent or guardian

Date of Birth * +

Gender *

Male

Female

Non-binary

Ethnicity (for reporting purposes only) *

Street Address *

Address Line 2

City *

State *

Zip Code *

County of Residence *

Phone Number *

Email Address *

Diagnosis (check all that apply) *

Mode of Treatment (check all that apply) *

Patient Financial Information

Household income from all sources *

Number of people residing in the household *

Did patient receive assistance in 2023? *

Yes

No

Unsure

Describe if other assistance has been utilized to obtain nutritional supplements *

Is there potential for future eligibility for above mentioned programs? *

Healthcare Professional Information

Social Worker Name *

Dialysis Unit/Transplant Unit *

Unit Address *

City *

State *

Zip Code *

Unit Phone Number *

Unit Fax Number

Social Worker Email Address *

Dietitian Name *

Dialysis Unit/Transplant Unit *

Address *

City *

State *

Zip Code *

Unit Phone Number *

Unit Fax Number

Email Address *

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