2024 Emergency Assistance Program

Overview
The Emergency Assistance program is based on the amount of funding available and is limited to the Foundation’s thirty-seven county service area. A $100 emergency grant, available once per calendar year, is issued when no other assistance is available. Unexpected high utility bills, auto repairs, and medical supplies are often situations where emergency grants are awarded.

ONE CURRENT bill will need to be uploaded with this application; a copy of the ENTIRE bill is required. The Foundation does NOT pay for the following: phone or cable TV charges, bills already paid, loans, rent, lease, mortgage, moving expenses, furniture or credit card payments.

Guidelines

Application must be completed by a healthcare professional.
Bills over $1,000 will NOT be considered.
Applications one or more months out of date will NOT be accepted.
Checks are mailed directly to third party providers, not the patient or healthcare professional.
A shut-off notice is required for utility bills.
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 *

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) *

Select access location if patient would like to receive a FREE identification band:

Healthcare Professional Information

Name *

What is your discipline? *

Social Worker

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 *

Self

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)? *

Yes

No

Does patient have private or secondary insurance? *

Yes

No

Is patient uninsured? *

Yes

No

Is patient a Veteran? *

Yes

No

Assessment

TO BE COMPLETED BY SOCIAL WORKER, 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

Professional Assessment *

Required Additional Data

Information provided to be utilized solely for program evaluation purposes.

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

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

Yes

No

Does the bill include a shut-off notice? (Utility bills that are NOT shut-off notices will be denied) *

Yes

No

Is the bill being submitted under the $1,000 threshold for consideration? (Bills over $1,000 will be denied) *

Yes

No

If home energy assistance is requested, has patient enrolled in HEAP (Home Energy Assistance Program)? *

Yes

No

Does the patient have a plan in place to avoid future issues with this expense? *

Yes

No

Please provide additional details about the plan to avoid future issues with this expense: *

Upload a current copy of the bill. *

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.