2024 Emergency Assistance Program

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.


  • 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  • Applications one or more months out of date will NOT be accepted.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

Gender Identity *
Race (for reporting purposes only) *
Ethnicity (for reporting purposes only) *
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

What is your discipline? *

Patient Financial Information

Is patient presently employed? *
Household Members *
List all dependents, and ages, living in household (adults, children, grandchildren, etc.)
Monthly Household Income *
 ApplicantSpouse/PartnerChild #1Child #2OtherTotal
Child Support
TANF (include Ohio Works First Program)
Food Assistance Program
Child Tax Rebate/Tax Credit
Unemployment Compensation
Other Assistance
Monthly Expenses *
 Monthly Payment Amount
Medication (out of pocket cost only)
Utilities (combined monthly average)
Transportation (bus fare, gas, taxi, Uber/Lyft)
Car Payment
Telephone (include cell phone)
Tuition/Education (include Student Loans)
Other Loan Payments
Credit Card Payments (total per month)
Doctor/Hospital (copays, deductibles, out of pocket)
Medicare (Premiums, Part B, Supplemental)
Other Medical Expenses
Other Expenses

Coverage Information

Is patient on Medicaid? *
Is patient covered by Medicare? *
Is patient covered by Medicare Part D? *
Is patient enrolled in LIS (Limited Income Subsidy/Extra Help)? *
Does patient have private or secondary insurance? *
Is patient uninsured? *
Is patient a Veteran? *
Does insurance cover transportation? *

Attestation of Need


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.

Unacceptable:  Client is applying for assistance due to financial hardship

Required Additional Data

Information provided to be utilized solely for program evaluation purposes.
Did patient receive funding from the Kidney Foundation of Ohio’s Emergency Assistance Program in 2023? *
Does the bill include a shut-off notice? (Utility bills that are NOT shut-off notices will be denied) *
Is the bill being submitted under the $1,000 threshold for consideration? (Bills over $1,000 will be denied) *
If home energy assistance is requested, has patient enrolled in HEAP (Home Energy Assistance Program)? *
Does the patient have a plan in place to avoid future issues with this expense? *

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

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