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Financial Assistance
Contact Information
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Individual with Down Syndrome
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(mm/dd/yyyy)
Assistance Request
Important Information

• All applications relating to medical appointment travel assistance, medical and therapy bills, special equipment, and prescriptions must be considered a medical necessity by a physician/therapist and must be accompanied by a letter from the primary care physician/therapist.

• Funding is available for the balance remaining after other insurance and/or Medicaid payments have been made.

• Families that do not have insurance, or are self-pay and are applying for assistance with medical bills or therapy bills must apply for Medicaid before assistance is rendered.

• Applicants will be notified if their application was approved and the amount of assistance to be provided.

• Limited funds are available. All applications may not be funded. Requests will be kept confidential.

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Medical Bills
Includes hospital or doctor’s office bills not covered by insurance and/or the insurance deductible. Please include a copy of the bill. The following questions are to help us confirm the need for assistance, and that other sources of assistance have already been utilized.
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We require these details to confirm medical expenses.
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First Name
Last Name
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Depending on any other diagnosis, we may be able to direct you to additional resources.
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We require you've filed a claim through insurance prior to awarding any financial assistance.
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We require you've exhausted any and all claims through the Medicaid program prior to awarding any financial assistance.
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(Family Support, Birth to Three, etc.)
Therapy Bills
Includes physical, occupational, speech, music, vision therapies, or other types of therapy not covered by insurance. Please include a copy of the bill. The following questions are to help us confirm the need for assistance, and that other sources of assistance have already been utilized.
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We require these details to confirm therapy expenses.
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First Name
Last Name
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Depending on any other diagnosis, we may be able to direct you to additional resources.
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We require you've filed a claim through insurance prior to awarding any financial assistance.
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We require you've exhausted any and all claims through the Medicaid program prior to awarding any financial assistance.
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(Family Support, Birth to Three, etc.)
Special Equipment
Includes glasses, hearing aids, orthodontics, orthotics (shoe inserts, remolding helmets, leg braces, etc.), wheelchairs and accessories, and feeding tubes. (This does not include cars, accessible vehicles, wheelchair ramps, bath lifts, or therapeutic toys not covered by insurance.) Please include a copy of the doctor’s prescription for the equipment. The following questions are to help us confirm the need for assistance, and that other sources of assistance have already been utilized.
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We require these details to confirm therapy expenses.
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XX Weeks, Months, Years?
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We may know of alternative sources for this equipment that we could put you in touch with.
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Depending on any other diagnosis, we may be able to direct you to additional resources.
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We require you've filed a claim through insurance prior to awarding any financial assistance.
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We require you've exhausted any and all claims through the Medicaid program prior to awarding any financial assistance.
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(Family Support, Birth to Three, etc.)
Prescription Medication
Includes any prescription medication prescribed for your child/adult that is not covered by insurance. Reimbursement for expenses will be made after payment to the pharmacy has been made. Please include a copy of the prescription and receipts from the pharmacy showing proof of payment. The following questions are to help us confirm the need for assistance, and that other sources of assistance have already been utilized.
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We require these details to confirm prescription expenses.
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Depending on any other diagnosis, we may be able to direct you to additional resources.
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We require you've filed a claim through insurance prior to awarding any financial assistance.
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We require you've exhausted any and all claims through the Medicaid program prior to awarding any financial assistance.
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(Family Support, Birth to Three, etc.)
Adoption Fees
Includes the adoption fees and childcare costs associated with adoption training. Please include a copy of the adoption fees and childcare costs. The following questions are to help us confirm the need for assistance, and that other sources of assistance have already been utilized.
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We require these details to confirm expenses.
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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First Name
Last Name
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Childcare costs associated with adoption training
Travel Assistance
To cover travel expenses (mileage, meals, lodging, and airfare.) Please include a confirmation of the appointment. Reimbursement for expenses will be made after the appointment. The following questions are to help us confirm the need for assistance, and that other sources of assistance have already been utilized.
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We require these details to confirm expenses.
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First Name
Last Name
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(mm/dd/yyyy)
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Total travelers including the individual with Down Syndrome.
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We may reimburse up to $0.50/mile

We may ask for further details if you travel via air.


We have set amounts per person per day for which we may be able to provide assistance.
Conferences and Seminars
Conferences or seminars must be in harmony with the mission and goals of New Directions Down Syndrome Association. Reimbursement will be up to $500 for the first adult family member and up to $100 for all other family members, up to 3 more family members. (Immediate family only.) Conference fees will be reimbursed at 50% before the conference and 50% after the conference. A letter of agreement will need to be signed stating that if money is not used for the intended purpose the money will be repaid to New Directions. All receipts will need to be turned in upon completion. Families will share experience with other New Directions families per the guidelines in the letter of agreement. The following questions are to help us confirm the need for assistance, and that other sources of assistance have already been utilized.
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Tell us so that we might encourage other members to attend.
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(mm/dd/yyyy)
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City + State
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First and Last name, one per row

Provide the year you attended


We may reimburse up to $0.50/mile

We may ask for further details if you travel via air.

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