Grant Application - Checklist

• Your child's social security number.
• Name 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.
• A description of the treatment, therapy, etc. your child's doctor has specifically prescribed. You can list up to five items.
• Your out of pocket cost of the treatment, therapy, equipment or service.
• How much, if any, your 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 your child's primary care medical doctor (M.D. or D.O.) that very clearly answers the following questions:
    • What is the child's specific medical condition(s)?
    • What specific impact does the child’s medical condition(s) have on the child’s life? (This may include medical, social, mental, etc.)
    • 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.
  • 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.