New Directions Down Syndrome · Financial Assistance

Contact Information

Name

*

First Name

Last Name

Email

*

Verify Email

*

Phone

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Individual with Down Syndrome

Name

*

Date of Birth

*

(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.

What kind of assistance are you requesting?

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Travel Assistance

Medical Bills

Therapy Bills

Special Equipment

Prescription Medication

Conferences or Seminars

Adoption Fees

What amount of assistance are you requesting?

*

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.

Please describe the medical issue related to this request.

*

Please upload a PDF or photos of the medical bills not covered by insurance for which you're seeking assistance.

*

We require these details to confirm medical expenses.

Primary Physician

*

First Name

Last Name

Does the individual with Down Syndrome have any other diagnosis? If so, please specify here.

*

Depending on any other diagnosis, we may be able to direct you to additional resources.

Do they have Insurance? If yes, with what company?

*

We require you've filed a claim through insurance prior to awarding any financial assistance.

Do they qualify for and/or have Medicaid? If yes, have you submitted a claim for this item? If no, have you applied?

*

We require you've exhausted any and all claims through the Medicaid program prior to awarding any financial assistance.

Are you receiving any financial assistance from other programs? If so, which program(s) and how much have they provided?

*

(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.

Please describe the type of therapy related to this request. Why is it necessary?

*

Please upload a PDF or photos of the therapy bills not covered by insurance for which you're seeking assistance.

*

We require these details to confirm therapy expenses.

Therapist

*

First Name

Last Name

Does the individual with Down Syndrome have any other diagnosis? If so, please specify here.

*

Depending on any other diagnosis, we may be able to direct you to additional resources.

Do they have Insurance? If yes, with what company?

*

We require you've filed a claim through insurance prior to awarding any financial assistance.

Do they qualify for and/or have Medicaid? If yes, have you submitted a claim for this item? If no, have you applied?

*

We require you've exhausted any and all claims through the Medicaid program prior to awarding any financial assistance.

Are you receiving any financial assistance from other programs? If so, which program(s) and how much have they provided?

*

(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.

Please describe the type of equipment you're requesting assistance with. Why is it necessary?

*

Please upload a PDF or photos of the prescription for the equipment from your physician, for which you're seeking assistance.

*

We require these details to confirm therapy expenses.

How long do you expect the equipment to be used?

*

XX Weeks, Months, Years?

Where do you plan to acquire this equipment, and how much does it cost?

*

We may know of alternative sources for this equipment that we could put you in touch with.

Does the individual with Down Syndrome have any other diagnosis? If so, please specify here.

*

Depending on any other diagnosis, we may be able to direct you to additional resources.

Do they have Insurance? If yes, with what company?

*

We require you've filed a claim through insurance prior to awarding any financial assistance.

Do they qualify for and/or have Medicaid? If yes, have you submitted a claim for this item? If no, have you applied?

*

We require you've exhausted any and all claims through the Medicaid program prior to awarding any financial assistance.

Are you receiving any financial assistance from other programs for this equipment? If so, which program(s) and how much have they provided?

*

(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.

What is the prescription medication, and why is it necessary?

*

Please upload a PDF or photos of the prescription not covered by insurance for which you're seeking assistance.

*

We require these details to confirm prescription expenses.

Pharmacy Name

*

Does the individual with Down Syndrome have any other diagnosis? If so, please specify here.

*

Depending on any other diagnosis, we may be able to direct you to additional resources.

Do they have Insurance? If yes, with what company?

*

We require you've filed a claim through insurance prior to awarding any financial assistance.

Do they qualify for and/or have Medicaid? If yes, have you submitted a claim for this item? If no, have you applied?

*

We require you've exhausted any and all claims through the Medicaid program prior to awarding any financial assistance.

Are you receiving any financial assistance from other programs? If so, which program(s) and how much have they provided?

*

(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.

Please upload a PDF or photos of the adoption fees and childcare costs for which you're seeking assistance.

*

We require these details to confirm expenses.

Adoption Agency

*

Adoption Agency Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Adoption Agency Contact

*

First Name

Last Name

Email

*

Verify Email

*

Phone

*

Total Adoption Fees

*

Total Childcare Costs

*

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.

Reason for the appointment?

*

Please upload a PDF or photos of the visit summary or appointment confirmation for which you're seeking assistance.

*

We require these details to confirm expenses.

Physician

*

First Name

Last Name

Appointment Date

*

(mm/dd/yyyy)

Number of Travelers

*

Total travelers including the individual with Down Syndrome.

Days Traveling

*

If you drove by car, how many total miles (round trip) did you travel?

We may reimburse up to $0.50/mile

If you traveled by air, what was the total cost of airfare?

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

If you had any overnight stays, what was the total cost for accommodations?

If you had to pay for meals, how many meals did you purchase?

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.

Why do you want to attend this event?

*

Tell us so that we might encourage other members to attend.

Name or Title of the Event?

*

Event Date

*

(mm/dd/yyyy)

Location

*

City + State

Attendee(s) Names

*

First and Last name, one per row

Have you attended this event before? If so, when?

Provide the year you attended

Total Registration Fees

If you drove by car, how many total miles (round trip) did you travel?

We may reimburse up to $0.50/mile

If you traveled by air, what was the total cost of airfare?

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

If you had any overnight stays, what was the total cost for accommodations?

Confirmation

*

I guarantee that the information in this request for funding is accurate, complete and true.

I understand that providing false information in any way will result in denial of this request.