2017 DONOR WORKSHEET AND ATTESTATION FORM REIMBURSEMENT OF TRAVEL AND SUBSISTENCE EXPENSES TOWARD LIVING ORGAN DONATION

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1 2017 DONOR WORKSHEET AND ATTESTATION FORM Thank you for applying to the National Living Donor Assistance Center (NLDAC). NLDAC pays for travel, lodging and meals for eligible living donors and their accompanying person(s) to travel to the transplant center. Please complete this worksheet and give to your transplant professional who will file the application on your behalf. You must provide a copy of your household income document: pay stubs, Federal Income Tax Return, disability statements or another document. The recipient household must complete a Recipient worksheet and submit income documents. Do not send this information to the NLDAC. We do not accept applications from patients. NLDAC cannot reimburse expenses that have already occurred. It is best to file applications 6 8 weeks before surgery or travel. The deadline is business days before travel/surgery If you have questions, please feel free to call NLDAC at If this application is not approved, the recipient can provide financial assistance to the donor. The National Organ Transplant Act (NOTA) allows for reasonable payment associated with the expenses of travel, housing and lost wages incurred by the donor of a human organ. NOTA does prohibit the buying and selling of organs. PERSONAL INFORMATION First Name Last Name Date of Birth Social Security Number Important: Full name should match name on social security card Gender Race Ethnicity Marital Status Education Male American Indian or Alaska native Hispanic Married Grade School Female Asia Not Hispanic Single High School/GED Black Divorced/Separated Post HS/Tech or Trade Native Hawaiian or other Pacific Islander Widowed Some College White College Grade 4 year Post College/Professional Organ Employment Status Please answer: Kidney Employed Full Time Homemaker/Caretaker Are you a U.S. citizen or lawfully admitted resident? Liver Employed Part Time Student Yes No Lung On Disability Leave Unemployed Have you signed the NLDAC Attestation Form? (See page 4) Retired Yes No RELATIONSHIP TO TRANSPLANT CANDIDATE I am the of the Recipient. Father Mother Sister Brother Son Daughter Spouse Other If Other, please specify: TYPE OF RELATIONSHIP: Blood Related Non Blood Related Unrelated Address Click (select) if Donor and Recipient live at the same address. Street: City: State: Zip: Location: Urban Suburban Rural Cell: Address: Phone: If application is approved, we will use your e mail address to send you the approval letter Send reimbursement to Address of Primary Residence? Yes No If no, provide alternative address: Street City State Zip Code Page 1 of 7

2 INCOME INFORMATION Please combine incomes if two or more members of the household YEARLY Household Income $ $ # Persons in Household # *Select the income document used to verify your household income and give a copy to your transplant professional. Federal Income Tax Return (Most Recent Year) Use Adjusted Gross Income Pay Stub(s) Use Gross Income W2 Use Gross Income Gov. Assist. Program (HUD, WIC, Food Stamps) Medicaid Social Security Statement Other document (i.e. disability statement, etc.) Loss of Income (NLDAC does not provide assistance for lost wages, but is collecting information for future reference.) Loss of Income while recovering from surgery: Exclude paid leave such as; sick time, vacation time, disability, etc); $ ACCOMPANYING PERSON(S) NLDAC allows one accompanying person to go on two trips to the Transplant Center or two persons to go on one trip. First Accompanying Person Click here if address is the same as Donor s address First Name: Last Name: Date of Birth: Address: City: State: Zip: Phone # Trip(s) Evaluation Only Evaluation and Surgical Procedure Evaluation and Medical Follow up Surgical Procedure Only Surgical Procedure and Medical Follow up Medical Follow up Only Second Accompanying Person Click here if address is the same as Donor s address First Name: Last Name: Date of Birth: Address: City: State: Zip: Phone: Trip Evaluation Only Surgical Procedure Only Medical Follow up Only Page 2 of 7

3 REIMBURSEMENT REQUEST Please complete the information below based on your best judgment. NLDAC develops travel budgets based on the application request and NLDAC policies. NLDAC can provide financial assistance for three trips to the Transplant Center for the donor and accompanying person(s). Budgets and be adjusted when travel plans are made. Additional trips may be approved for donor complications or health related issues. HOTEL EXPENSES Will the donor require a hotel room/lodging. If yes, how many nights? Will the accompanying person require a separate room? If yes, how many nights? Evaluation Trip Up to 2 nights Surgery Trip Up to 14 nights Follow up Trip Up to 1 night PER DIEM/FOOD EXPENSES (NO HOTEL BUT AWAY FROM HOME) Up to 2 days Up to 14 days Up to 1 day If a hotel is not needed, how many days will the donor and accompanying person be away from home? TRANSPORTATION EXPENSES How is the donor traveling to Transplant Center? Air, Car, Bus, Train If driving your own car, how many miles will be traveled round trip? How is the acc. person(s) traveling to Tr. Center? Air, Car, Bus, Train If acc. person travels in a separate car, how many miles round trip? Will the donor need a rental car? For how many days? (for evaluation: 2 days; for surgery: up to 14) How many days of parking requested? Estimate Daily Parking costs at hospital/hotel $ $ $ Estimate Tolls (if any) $ $ $ Estimate cost If riding a cab/shuttle/uber $ $ $ Additional information about your trip for our consideration: RESEARCH QUESTIONS How you answer these questions is not going to affect your eligibility to receive the travel grant. Your answers may help NLDAC demonstrate the need to keep funding for the grant and may help us learn how to tailor assistance to donors in the future. Thank you. True False The NLDAC program will make it possible for me to donate an organ. The NLDAC program will help my stress and give me less worry. I had hoped that the recipient would have received a deceased donor organ. In addition, I wish that NLDAC could assist with lost pay or vacation/leave. Page 3 of 7

4 Attestation Form Donor Candidate Transplant Professionals: Please retain this form in patient medical record. For UnitedHealthcare fully insured donors, please send worksheet and attestation form via secure to I, as a live organ donor candidate, have truthfully and completely provided all the information requested in the application for reimbursement of travel and subsistence toward living organ donation. The transplant center personnel have informed me of what constitutes valuable consideration and to the best of my understanding, I am in full compliance with Section 301 of NOTA (42 U.S.C. 274e), which stipulates, in part, that it shall be unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation if the transfer affects interstate commerce. My decision to undergo live organ donation was not motivated by the exchange of any valuable consideration. I do not have any other information indicating that valuable consideration is being exchanged in connection with this donation procedure. I understand that NLDAC, under Federal law, cannot provide reimbursement to any living organ donor for travel and other qualifying expenses if the donor can receive reimbursement for those expenses from any of the following sources; (1) Any state compensation program, an insurance policy, or a Federal or State health benefits program: (2) an entity that provides health services on a prepaid basis; or (3) the recipient of the organ. I give permission for the transplant center to share my information with the National Living Donor Assistance Center. I acknowledge that reimbursement may be subject to federal and/or state income tax reporting. Applicant is responsible for contacting a qualified tax advisor to determine tax liability. NLDAC nor other entities providing reimbursement are responsible for any tax consequences of the travel reimbursement program (for UnitedHealthcare fully insured donors only) I give permission to NLDAC to provide the information in this application to other entities, including the recipient s health insurer, for review and potential reimbursement for travel and other qualifying expenses. The health insurer will only use or disclose the information in accordance with the applicable law. In signing this form, I declare, under penalty of perjury under the Federal and State laws that all the information I have provided is true, correct and complete. I further understand that Federal and State law may provide for penalties of fine and/or imprisonment or denial of the requested travel and subsistence reimbursement assistance if I do not tell the truth when applying for assistance under the live donor reimbursement program or if I conceal or fail to disclose facts regarding the information supplied in the application process. Donor Signature: Date: Transplant Center Application Filer: Date: Page 4 of 7

5 2017 RECIPIENT APPLICATION WORKSHEET The National Living Donor Assistance Center (NLDAC) provides assistance with the donor s travel expenses to the transplant center. This worksheet is part of the donor s application. Give this completed worksheet to your transplant professional who will file the application on behalf of your donor. Do not send this worksheet to NLDAC. NLDAC eligibility is based on 300% of the HHS Federal Poverty Guidelines (see chart page 3). If the recipient household income is above these guidelines, NLDAC assumes the recipient can pay for their own donor s travel expenses. If needed, a waiver for financial hardship may be requested. You must provide proof of household income (i.e. Pay stub(s), Federal Income Tax Return, Disability statements or other documents. We recommend applications be filed 6 8 weeks before travel/surgery, but no later than 10 business days, and no later than 15 business days if the recipient household income is above these guidelines. We do not assist recipients with travel expenses. If you have questions about this worksheet, please call *If this application is not approved, the recipient can provide financial assistance to the donor. The National Organ Transplant Act (NOTA) allows for reasonable payment associated with the expenses of travel, housing and lost wages incurred by the donor of a human organ. NOTA does prohibit the buying and selling of organs. PERSONAL INFORMATION First Name Last Name Date of Birth Social Security Number Street Address City State Zip Code Gender Race Ethnicity Male Female American Indian or Alaska native Asian Black Native Hawaiian or other Pacific Islander White Hispanic Not Hispanic Are you a U.S. citizen or lawfully admitted resident? Yes No Have you signed the Attestation Form? (See page 2) Yes No Are you currently on dialysis? Yes No Does your health insurance provide a travel benefit for your living donor? Yes No If yes, what benefits are covered by your insurance (e.g. hotel, airfare?) If you have insurance coverage through UnitedHealthcare, please provide policy number to verify coverage and member ID INCOME INFORMATION & CALCULATING HOUSEHOLD INCOME Use Gross Income to calculate income with pay stubs; Adjusted Gross Income for Federal Income Tax Return Yearly/Annual Household Income $ # Household Members # Select which income document was used to verify your household income and give a copy to your transplant professional: Federal Income Tax Return (Most Recent Year) W2 Pay Stubs Medicaid Social Security Statement Gov. Assist. Program (HUD, WIC, Food Stamps) Other document (i.e. disability statement, etc.) Page 5 of 7

6 Attestation Form Recipient Candidate Transplant Professionals: Please retain this form in patient medical record. For UnitedHealthcare full insured donors, please send worksheet and attestation form via secure to I,, as a transplant candidate, have truthfully and completely provided all the information requested in the application for reimbursement of travel and subsistence toward living organ donation. The transplant center personnel have informed me of what constitutes valuable consideration and to the best of my understanding, I am in full compliance with Section 301 of NOTA (42 U.S.C. 274e), which stipulates, in part, that it shall be unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation if the transfer affects interstate commerce. My decision to undergo live organ transplantation was not motivated by the exchange of any valuable consideration. I do not have any other information indicating that valuable consideration is being exchanged in connection with this donation procedure. I understand that NLDAC, under Federal law, cannot provide reimbursement to any living organ donor for travel and other qualifying expenses if the donor can receive reimbursement for those expenses from any of the following sources; (1) Any state compensation program, an insurance policy, or a Federal or State health benefits program: (2) an entity that provides health services on a prepaid basis; or (3) the recipient of the organ. I give permission for the transplant center to share my information with the National Living Donor Assistance Center. (for UnitedHealthcare fully insured transplant candidates only) I give permission to NLDAC to provide the information in the application to other entities, including my health insurer, for review and potential reimbursement for travel and other qualifying expenses for my donor. The health insurer will only use or disclose this information in accordance with applicable law. In signing this form, I declare, under penalty of perjury under the Federal and State laws that all the information I have provided is true, correct and complete. I further understand that Federal and State law may provide for penalties of fine and/or imprisonment or denial of the requested travel and subsistence reimbursement assistance if I do not tell the truth when applying for assistance under the live donor reimbursement program or if I conceal or fail to disclose facts regarding the information supplied in the application process. Recipient Signature: Date: Transplant Center Application Filer: Date: Page 6 of 7

7 FINANCIAL HARDSHIP WAIVER WORKSHEET 2017 IMPORTANT: Recipients Please skip this page if your household income is equal to or below the NLDAC eligibility guidelines. NLDAC Eligibility Guidelines Recipient Income Threshold 300% HHS Federal Poverty Guidelines (FPG) 2017 # Person 48 Contiguous Household States and D.C. Alaska Hawaii 1 $36,180 $45,180 $41,580 2 $48,720 $60,870 $56,010 3 $61,260 $76,560 $70,440 4 $73,800 $92,250 $84,870 5 $86,340 $107,940 $99,300 6 $98,880 $123,630 $113,730 7 $111,420 $139,320 $128,160 8 $123,960 $153,360 $141,030 Recipients: Under federal law, NLDAC cannot pay for the donor s travel expenses if the recipient can pay those costs. If your household income is above the NLDAC guidelines but you will have difficulty providing support for the donor, NLDAC provides an exception to this rule, and a waiver for financial hardship may be requested. The NLDAC financial hardship waiver process requires a complete evaluation by the transplant professional, NLDAC and HRSA (Health Resources and Services Administration) using fact specific analysis of information captured in the form below. Your allowable out ofpocket expenses must bring your income within the NLDAC guidelines. For example, if your income is $5,000 above the NLDAC eligibility guidelines, you will need to demonstrate $5,000 in Please list monthly or one time out of pocket allowable expenses for your entire household. NLDAC will calculate annual expenditures based on the information provided in the worksheet. Regular living expenses (rent, utilities, etc.) should not be included. If you have questions or need more information, call NLDAC toll free at First Name: Phone: Last Name: (NLDAC staff may call you to clarify information on this worksheet) 1. $ Monthly out of pocket insurance premiums 2. $ Monthly out of pocket pharmacy co pays before the transplant 3. $ Monthly out of pocket pharmacy co pays after the transplant (Estimated by transplant professional) 4. $ Monthly out of pocket physician co pays 5. $ Monthly out of pocket labs or other medical co pays not listed above 6. $ Total hospital/medical bills owed not covered by insurance (not monthly) 7. $ Loss of income due to surgery (excluding paid time off/disability pay) please describe in *Comments 8. # Miles Monthly round trip mileage for medical appointments (pre transplant) 9. Monthly transportation tolls (pre transplant): $ Monthly Parking (pre transplant): $ 10. How will you travel to the transplant center for your surgery trip? Air Car Bus Train 11. # Miles If driving, how many miles round trip to the transplant center? 12. Yes/No Will you need to stay in a hotel near the transplant center after your transplant surgery? 13. # Nights If you will stay in a hotel, how many nights will you stay? 14. # Trips In the first 3 months after your transplant, how many trips (estimate) will you make to the hospital? 15. $ Monthly dependent care for family member not living in the household (ex. child support) describe in *Comments 16. $ Other expenses describe in *Comments If loss of income, monthly dependent care for a family member not living in household, or other allowable expenses are noted above, please describe those expenses here. You may attach an additional page if desired. *Comments: Page 7 of 7