Spin for Kids Fund Allocation Application

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Joseph Webster
6 years ago
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To be considered for your request of Spin For Kids fund allocation, all applicants must complete the Spin for Kids Fund

1 Spin for Kids Fund Allocation Application Spin for Kids provides funding for therapy, services and equipment to children from birth through 19 years of age with special needs within the Spin For Kids Altru Health System service area. To be considered for your request of Spin For Kids fund allocation, all applicants must complete the Spin for Kids Fund Allocation Application packet. Be aware that any information not provided could result in a delay of your request or eliminate your request from being considered. 1

2 Spin for Kids Application Patient Name: Telephone: Address: Parent/Guardian s Name: Telephone: Address: (if different from patient): Number of persons in household: Adults Children under 18: Medical Information Patient s Diagnosis: Primary Physician: Clinic/Hospital: Other physicians (if applicable): Clinic/Hospital: Other: Financial Information: See the attached Spin for Kids Financial Eligibility Criteria guidelines. Please attach the most recent federal tax return Form 1040 without schedules. Insurance Information Primary insurance: Policy #: (Example: Blue Cross, Medica, Medicaid, Tricare) Additional or secondary insurance: Policy #: Additional or secondary insurance: Policy #: I am aware that any information not provided could eliminate my request from being considered. The information stated in this application is correct to the best of my knowledge. Name Relation to patient Today s Date Date Address Telephone 2

3 Spin For Kids Financial Eligibility Criteria Financial eligibility will be established based upon tax returns and other financial records of the patient or his/her financial guarantor, if necessary. The applicant will be required to provide a copy of the most recent year s federal tax return and complete a certification that the applicant does not have sufficient assets to pay for the requested funds without undue burden. The requested tax return will be the individual tax return for the patient or financial guarantor, the joint return for married couples filing jointly, or both individual returns for married couples filing separately. In cases where the financial guarantors of the patient are parents who are not married (whether divorced or otherwise), the tax return of each financial guarantor will be reviewed as possible, given social circumstances. For any applicant, the Spin for Kids Allocation Committee reserves the right to request additional financial information in its discretion. The patient or financial guarantor can meet financial eligibility criteria in two ways: 1. If taxable income is equal to or less than 500% of the Federal Poverty Guidelines as amended from time (see table below for 2017 Federal Poverty Guidelines US Department of Health and Human Services), or 2. If taxable income is greater than 500% of the Federal Poverty Guidelines, but the annual medical expenses associated with the patient s condition are 7.5% or greater than the taxable income. Only expenses in excess of the 7.5% threshold will be eligible for reimbursement. In addition to the other limitations described above, the Spin for Kids Allocation Committee may grant partial reimbursement based upon the family s income and perceived economic hardship as determined by the Spin for Kids Allocation Committee in its discretion. In addition, the Spin for Kids Allocation Committee may deviate from the Federal Poverty Guidelines for good cause. Applicants for reimbursement must use the Spin for Kids Fund Allocation application. Family Size 2017 Federal Poverty Level $12, $16, $20, $24, $28, $32, $37, $41, % $60, $81, $102, $123, $143, $164, $185, $206,

4 Spin For Kids Application Patient Name: Birth date: Diagnosis: Phone #: Parent s Name: Address: _ Funds Requested Type of Therapy, Services or Equipment Make payment to Cost Amount insurance will cover, if applicable Amount of Spin for Kids funds requested Total Amount: You must attach copies of the following, as applicable, to qualify for Spin For Kids Funds: Description of the requested therapy, services or equipment. Proof of price/cost of requested therapy, services or equipment. A prescription signed by a physician, physician assistant or nurse practitioner. Supporting documentation from a physician, physician assistant, nurse practitioner, Physical, Occupational or Hand Therapist, Speech Language Pathologist or Healthcare Specialist, etc. substantiating the need for the request A copy of your Explanation of Benefits (EOB) from your insurance company. A copy of the appeal letters or an explanation of why an appeal is not appropriate for services rejected by insurance. Proof of receipt for payments of therapy, services or equipment. At least two estimates for home renovation or vehicle adaptations. I understand that the Spin for Kids Allocation Committee will review and discuss my application and requested attachments in the decision process for fund allocation. I am aware that any information not provided, could eliminate my request from being considered. Funds will be disbursed on a pro-rated basis to qualified applicants, based on available dollars. Deadlines: January 1 April 1 July 1 October 1 Send application to: Diane Gunderson, Chairperson Spin for Kids Allocation Committee Director of Physical Medicine Services Altru Rehabilitation Center 1300 South Columbia Road Grand Forks, ND (phone) (fax) dgunderson@altru.org 4

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