2024-2025 Lake County Patient Assistance Program

General Information
The Kidney Foundation of Lake County is a not-for-profit organization that provides temporary aid to patients impacted by kidney disease and transplant patients who need financial help. 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 January 31^st to maintain funding on program. Priority is given to people who are uninsured or underinsured.

Guidelines

Patient assistance application must be completed annually without exception. If you have received assistance in a prior year, a new application must be completed for 2024-2025.
The Kidney Foundation of Lake 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.
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.

Individual Program Overview

Medication Assistance: Priority will be given to patients who have no other form of assistance such as Medicaid, Medicare or private insurance. Patients will receive a grant to purchase medications through an approved Kidney Foundation of Ohio pharmacy, based on funding.

Transportation Assistance: Mileage Reimbursement is available for dialysis, nephrology appointments or transplant work-ups. Priority will be given to long distance patients. The average reimbursement is based on funding.

Emergency Grants: Emergency grants are available one-time per year, based on funding. Grant payments are made to third party providers, not to the patient. The ENTIRE copy of ONE bill for which assistance is requested will need to be included in this application. The Foundation does not pay for the following: long-distance phone calls, entertainment numbers, or non-essential phone charges, bills already paid, loans, rent, lease, mortgage, real estate costs or credit cards.

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 *

Are you a United States citizen? *

Yes

No

Zip Code *

County of Residence *

Phone Number *

Email Address *

Diagnosis (check all that apply) *

Mode of Treatment (check all that apply) *

First date of dialysis or date of transplant * +

To receive a FREE ID Band for patient, select access location (or transplant):

Healthcare Professional Information

Healthcare Professional 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

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

Additional Household Income

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

Total combined monthly income from all sources listed above *

Annual income (number listed above x 12) *

Total monthly income from all sources NOT listed above *

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

Does patient's insurance cover transportation? *

Yes

No

Is patient a Veteran? *

Yes

No

Attestation of Needs

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

The Kidney Foundation depends on your honest and accurate assessment of the patient’s financial need. If this application is submitted for an Emergency Grant request, please include in your statement the plan of action to prevent future issues.

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 Needs *

Medication Assistance Program

Are you applying for Medication Assistance? *

Yes

No

Are you 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 *

Did patient receive funding from the Medication Assistance Program in 2023-2024? *

Yes

No

Number of medications patient takes on a daily basis *

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

Yes

No

Patient needs help paying for how many medications? *

If provided assistance, how would you apply the funds? Check all that apply *

Medication(s) not covered by insurance

Nutritional supplements

Copay/deductible assistance

Over the counter prescriptions

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

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

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

+-

Transportation Assistance Program

Are you applying for Mileage Assistance? *

Yes

No

Does patient have at least one standing appointment related to kidney disease? (i.e dialysis, transplant work-ups) *

Yes

No

Type of appointment *

Primary source of transportation for dialysis/transplant appointments *

Did patient receive Transportation Assistance from the Kidney Foundation of Ohio in 2023-2024? *

Yes

No

Number of appointments relating to kidney disease patient is currently SCHEDULED for per month *

Number of appointments relating to kidney disease ACTUALLY attended last month *

Number of miles to dialysis treatment or transplant appointment (ONE WAY) *

Emergency Grant Program

Are you applying for an Emergency Grant? *

Yes

No

Purpose for Emergency Assistance *

Amount Requested (max grant amount is $200) *

Attach copy of bill *

Did patient receive Emergency Assistance from the Kidney Foundation of Ohio in 2023-2024? *

Yes

No

Has patient had a previous disconnection notice in the past 12 months? *

Yes

No

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

Yes

No

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

Yes

No

Please provide additional details about patient's plan 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.

Save & Return

Use an account to return to saved work.