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 31st to maintain funding on program. Priority is given to people who are uninsured or underinsured.


  • 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

Gender Identity *
Race (for reporting purposes only) *
Ethnicity (for reporting purposes only) *
Are you a United States citizen? *
Diagnosis (check all that apply) *
Mode of Treatment (check all that apply) *
To receive a FREE ID Band for patient, select access location (or transplant):

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 *
Child Support
TANF (include Ohio Works First Program)
Food Assistance Program
Child Tax Rebate/Tax Credit
Unemployment Compensation
Other Assistance
Additional Household Income
 Child #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? *
Does patient's insurance cover transportation? *
Is patient a Veteran? *

Attestation of Needs


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. 


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.

Medication Assistance Program

Are you applying for Medication Assistance? *
Are you requesting nutritional supplements? *
If requesting Nutritional Supplements, a Nutritional Supplement Form will need to be uploaded below.

Did patient receive funding from the Medication Assistance Program in 2023-2024? *
Is the patient able to afford all prescribed medications or nutritional supplements? *
If provided assistance, how would you apply the funds? Check all that apply *
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. *

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

Transportation Assistance Program

Are you applying for Mileage Assistance? *
Does patient have at least one standing appointment related to kidney disease? (i.e dialysis, transplant work-ups) *
Primary source of transportation for dialysis/transplant appointments *
Did patient receive Transportation Assistance from the Kidney Foundation of Ohio in 2023-2024? *

Emergency Grant Program

Are you applying for an Emergency Grant? *

Did patient receive Emergency Assistance from the Kidney Foundation of Ohio in 2023-2024? *
Has patient had a previous disconnection notice in the past 12 months? *
If requesting energy assistance, is patient enrolled in HEAP (Home Energy Assistance Program)? *
Does 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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