Grant Application - Checklist

• Your child's social security number.
• Name, phone number and policy number of your child's current commercial health benefit plan. Medicaid, Medicare, SCHIP (which may be called various names by each state), HIS or other state or federally subsidized health insurance programs given to those without insurance or with low incomes are not eligible.
• A brief description of your child's medical condition(s).
• A description of the medical treatment, medical therapy, etc. your child's doctor has specifically prescribed. You can list up to five medical items in the application.
• Your monthly or one-time out of pocket cost of the medical treatment, medical therapy, etc. Out of pocket cost information should be what you pay after insurance, OR what you pay if insurance does not cover the item. If you do not know your monthly or one-time out of pocket cost information, please work with your provider and insurance company to determine your out of pocket cost. Do not overestimate your costs.
• How much of the cost, if any, your health insurance will help pay for.
• The child's primary care medical doctor (M.D. or D.O.) name, phone number and mailing address.
• An outline of your finances - monthly income, monthly expenses and total assets (bank accounts, investments, 401(k), etc.).
• The Foundation will request that some paper work be sent to us via mail at the end of the online application. We will ask for:
  • A one-page letter from an M.D. or D.O. that very clearly answers the following questions:
    • What is the child's specific medical condition(s) and diagnoses?
    • What specific impact does the child’s medical condition(s) have on the child’s life? (This may include medical, social, mental, etc.)
    • What is the severity of the child’s medical condition(s) and diagnoses?
    • What specific therapy, treatment and/or medical services does the doctor recommend?
    • Why does the doctor recommend these?
    • Has the child received the therapy, treatment and/or medical services before? If yes, have they been effective?
    • What result does the doctor hope to achieve with this therapy, treatment and/or medical services?
  • Your IRS 1040 from the previous tax year that specifically lists your child as a dependent. We require the 2011 IRS 1040.
  • If you are requesting help with anything that your insurance company will not cover at all (0%), we will ask for proof. Proof will be a letter from your commercial health insurance company, or a copy of your benefits handbook that clearly states what is not covered, or an EOB, dated within the last sixty days, that shows what is not covered.
• The Foundation may also request additional information from you after the application is submitted.