2024 Medication Assistance Program

Overview
This program is based on the amount of funding available and is limited to the Foundation’s thirty-seven county service area. The program provides financial aid to help individuals purchase renal medications or nutritional supplements through an approved pharmacy. If approved, a renewal form must be submitted by July 1st to maintain funding on program. Priority is given to people who are uninsured or underinsured.

Guidelines

Application must be submitted by a healthcare professional.
Medication assistance cannot be awarded in conjunction with transportation assistance.
The Kidney Foundation of Ohio’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.
U.S. Federal Poverty Guidelines will be used to determine the patient’s level of eligibility. Intentionally misleading information on the application is cause for denial of assistance.
There is a minimum two-week review process for all applications.
Programs may be changed or discontinued at any time without notice.

For questions, contact (216) 771-2700 or programs@kfohio.org.

Patient Information

Patient First Name *

Patient Last Name *

If a minor, name of parent or guardian

Date of Birth * +

Gender Identity *

Male

Female

Non-binary

Race (for reporting purposes only) *

Ethnicity (for reporting purposes only) *

Hispanic or Latino

Non-Hispanic or Latino

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) *

Requesting nutritional supplements? *

Yes

No

If requesting Nutritional Supplements, a Nutritional Supplement Form will need to be uploaded below.

Upload the completed Nutritional Supplement Form *

Requesting Medication Assistance for a patient in Summit County? *

Yes

No

What is the preferred pharmacy? *

ExactCare Pharmacy

Sand Run Pharmacy

To receive a FREE ID Band for patient, select their access location:

Healthcare Professional Information

Name *

What is your discipline? *

Social Worker

Dietitian

Other Other

Dialysis Unit/Transplant Unit *

Unit Address *

City *

State *

Zip Code *

Unit Phone Number *

Unit Fax Number

Email Address *

Physician Name *

Patient Financial Information

Is patient presently employed? *

Yes

No

Household Members *

Patient

Spouse/Partner

Dependents

List all dependents, and ages, living in household (adults, children, grandchildren, etc.)

+-

Monthly Household Income *

	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Salary	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
SSI/SSDI	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Pension	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Child Support	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
TANF (include Ohio Works First Program)	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Food Assistance Program	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Child Tax Rebate/Tax Credit	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Unemployment Compensation	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Other Assistance	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total

Total combined monthly income from all sources listed above *

Annual income (number listed above x 12) *

Monthly Expenses *

	Monthly Payment Amount
Medication (out of pocket cost only)	Monthly Payment Amount
Rent/Mortgage	Monthly Payment Amount
Utilities (combined monthly average)	Monthly Payment Amount
Groceries	Monthly Payment Amount
Transportation (bus fare, gas, taxi, Uber/Lyft)	Monthly Payment Amount
Insurance	Monthly Payment Amount
Car Payment	Monthly Payment Amount
Entertainment	Monthly Payment Amount
Telephone (include cell phone)	Monthly Payment Amount
Tuition/Education (include Student Loans)	Monthly Payment Amount
Other Loan Payments	Monthly Payment Amount
Credit Card Payments (total per month)	Monthly Payment Amount
Doctor/Hospital (copays, deductibles, out of pocket)	Monthly Payment Amount
Medicare (Premiums, Part B, Supplemental)	Monthly Payment Amount
Other Medical Expenses	Monthly Payment Amount
Other Expenses	Monthly Payment Amount

Total monthly expenses from all sources listed above *

Coverage Information

Is patient on Medicaid? *

Yes

No

Is patient covered by Medicare? *

Yes

No

Is patient covered by Medicare Part D? *

Yes

No

Is patient enrolled in LIS (Limited Income Subsidy/Extra Help)? *

Yes

No

Does patient have private or secondary insurance? *

Yes

No

Is patient uninsured? *

Yes

No

Is patient a Veteran? *

Yes

No

Attestation of Need

TO BE COMPLETED BY SOCIAL WORKER, DIETITIAN, NEPHROLOGIST, UROLOGIST, OR NURSE.

Provide as many details as possible. Funding is allocated to individuals who demonstrate the most need. Include the circumstances behind the applicant’s request.

EXAMPLES:

Acceptable: Client is unable to work due to dialysis treatments. They are requesting assistance because their copays for medication is a burden to them. The client has been unable to purchase necessary medications for 3 months. DO NOT USE THIS EXAMPLE.

Unacceptable: Client is applying for assistance due to financial hardship

Attestation of Need *

Required Additional Data

TO BE COMPLETED BY HEALTHCARE PROFESSIONAL

Information provided to be utilized solely for program evaluation purposes.

What was the patient's dialysis start date? * +

If provided assistance, how would funds be applied? (check all that apply) *

Medication(s) not covered by insurance

Nutritional supplements (additional supplement form MUST be filled out and attached)

Copay/deductible assistance

Over the counter prescriptions

Did patient receive funding from the Kidney Foundation of Ohio's Medication Assistance Program in 2023? *

Yes

No

Unsure

Is the patient able to afford all prescribed medications or nutritional supplements? *

Yes

No

Number of PRESCRIBED medication/supplements? *

Patient needs help paying for how many medications/supplements? *

A current medication list will need uploaded (as a word document or PDF), or can be listed individually within this form. Please select how you could like to provide a current medication list. *

Upload a current medication list document

List current medication within this form

List current medications. Include both prescription medications and over the counter medications. *

+-

Upload a current medication list. Include both prescription medications and over the counter medications. *

At this time, you can Save Progress and finish completing the application at another time or select Next to sign and submit the application.

Save & Return

Use an account to return to saved work.