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.
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.
Client is applying for assistance due to financial hardship