LIVING ORGAN DONOR EXPENSE REIMBURSEMENT PROGRAM (LODERP) APPLICATION FORM

Transcription

1 LIVING ORGAN DONOR EXPENSE REIMBURSEMENT PROGRAM (LODERP) APPLICATION FORM I, the undersigned, understand that in making application to The Kidney Foundation of Canada for expense reimbursement, I am required to provide certain information to the Foundation, including: SECTION A: LIVING ORGAN DONOR APPLICANT INFORMATION Name: Gender: Male Female Home Phone: Home address: City: Province: Postal Code: Cell or Work # : Transplant Program: kidney liver lung Date of Last Assessment: Estimated Date of Donor Surgery: Recipient s Name: (If directed donation) Are you eligible to receive funding from any other source? Yes No If yes, please explain: Have you received funding from any other source? Yes No If yes, please explain: Are you eligible for paid time off work (i.e. leave of absence, sick time, vacation time, short term disability)? Yes No If yes, what are you eligible for? Are you eligible for Employment Insurance Sickness Benefits? Yes No LODERP: July 16, 2010 Page 1 of 5

2 Have you ever made a claim to LODERP previously? Yes No If yes, please provide date of last application: Will you be applying for LODERP Loss of Income Subsidy? Yes No If yes, you and your employer (if applicable) are to complete the Income and Benefit Verification Form. I, the undersigned, have to the best of my knowledge, provided accurate and complete information. I understand that the personal information provided in this application will be used only for the purposes of establishing my eligibility for expense reimbursement from,. I further understand that KFoC may compile statistical information to report on the expense reimbursement program or for demographic purposes; no identifying personal information will be used for such reporting purposes. If you have concerns about how KFoC manages your personal information please contact the Privacy Office at privacy@kidney.ab.ca Signature of applicant: Organ Donation Saves Lives Talk to Your Family About Your Wishes Les don d organes sauvent des vies descutez-en avec votre famille LODERP: July 16, 2010 Page 2 of 5

3 SECTION B: LIVING DONOR EXPENSE CLAIM FORM Name: Phone: Expense Itemization: Original Receipts are Required Expense Category Travel Mileage must be over 60 km one way Economy level flights only Details Mileage: 0.41/km = *Attach mileage record with Google map (see Section C) Airport Shuttle/Taxi Arrival Departure Bus Arrival Departure Air Arrival Departure Total Type of Visit A = Assessment S = Immediate post surgery Maximum for air, ground or mileage Travel reimbursement is restricted to transplant centre for final donor evaluation or to actual donor procedure. Parking or Public Transit Costs Total 20/day for up to 7 LODERP: July 16, 2010 Page 3 of 5

4 Expense Category Meals Donor lives over 100km from the transplant hospital Details Type of Visit A = Assessment S = Immediate post surgery Total Maximum 40/day for up to 5 Meal Allowance Donor staying with family or friend Accommodation Donor lives over 100km from the transplant Total hospital Total In lieu of accommodation and meals. 30/day for up to 5 125/night for up to 5 Other Childcare for nonworking parent Total For KFoC use only: Date received: Application approved: Yes or No Total expenses: Comments: ID Code: Coordinator initials: Date reimbursement sent: LODERP: July 16, 2010 Page 4 of 5

5 SECTION C: MILEAGE RECORD Name: Phone: Mileage of 60 km or less one way will not be reimbursed. Travel reimbursement is restricted to transplant centre for final donor evaluation or to actual donor procedure. Mileage Tracking = 0.41/km Date Details/Purpose of Trip Km Total For KFoC use only: Date received: Application approved: Yes or No Total expenses: Comments: ID Code: Coordinator initials: Date reimbursement sent: LODERP: July 16, 2010 Page 5 of 5