lendahand

LEND A HAND UP APPLICATION

FOR BOOST FUNDING - Part 2

Information about Medical Hardship

To be completed by the individual or parent/guardian

who will receive proceeds from campaign
Boost funding, online giving and other resources are awarded to qualifying fundraising campaigns based on medical diagnosis, financial challenges, residency (currently Cass County, ND and Clay County, MN) and fundraising activities. Applications are reviewed weekly. Funding is prioritized for individual/families burdened by substantial expenses due to a catastrophic medical condition.

Timelines and Award Criteria

Funding: Lend A Hand Up will award a $100 boost for every $500 raised, up to a $5000 total boost per family. ($1000 maximum boost per donor applies)

Online Campaign: Applications for boost funding and other resources may be submitted at any time. If approved, Boost Funding is awarded based on online gifts made through lendahandup.org, effective upon approval date (90 day maximum campaign). Gifts raised through other sites or by cash/check are not eligible.

Benefit/Events: Applications for boost funding and other resources must be submitted at least 30 days in advance of a scheduled benefit/community event (event must be open to the public). If approved, Boost Funding is awarded based on online gifts made through lendahandup.org, as well as cash and check gifts deposited into an established benefit fund, effective upon the formal approval date (90 day maximum campaign). Gifts raised on other online sites are not eligible for boost funding awards.

Note: A benefit/event may be added to an online campaign while in process without needing to submit a new application as long as event information is received and approved before the end of the 90 day campaign.
Part 2 of the application requests information about the medical hardship, to be completed by the individual or parent/guardian who will receive proceeds from the fundraising campaign.

Please review the eligibility checklist HERE or at lendahandup.org/apply-for-help/ before proceeding with the Lend A Hand Up Application. All requirements must be met for the application to be considered and approved.

You must have the following information available to complete the application. Please forward documentation to the Lend A Hand Up office.
- Information about the life threatening and/or incapacitating illness or injury that limits activities of daily living and results in substantial out-of-pocket expenses of $5,000 or more.
- Out of pocket (non-covered) expense totals related to medical care and treatment for each of the following categories:
  - Medical Care
  - Prescription/Medications/ Equipment/Supplies
  - Health Coverage Premiums
  - Travel/Gas/Lodging/Food
  - Non-Medical expenses creating hardship due to medical condition
- Documents verifying local residency, name, age (driver's license or birth certificate)
- Documents verifying medical diagnosis/condition and provider (letter from doctor or discharge statement).
- (Optional) Summary report verifying total paid and/or billed for the past 12 months for the medical institute, pharmacy, etc. (please do not send individual billing statements)
Note: Expenses may reflect paid, billed and estimated costs for the past and/or future 12 months. Billed and/or paid medical expenses may be determined by requesting a report from a clinic/hospital or pharmacy showing your self-paid total for the past 12 months. Future expenses may be estimated based on treatment plans, deductibles, copays and coinsurance. Contact your insurance company and/or the customer service department of the clinic/hospital for assistance.
If you'd prefer to print and complete an application on paper, do not use this form; instead use the attached printable PDF application.

To forward documentation or if you have questions about required information and guidelines, please contact the program office: jpeinovich@dakmed.org or 701-356-2661. Fax: 701-271-0408.
Part 2 Printable PDF (Right click on PDF image, then print or save as.)
Name *

First Name Last Name

Section 2A: Recipient
Recipient Name *

First Name Last Name
Age *
Gender *

Male Female

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

County Residency *

Cass (ND) Clay (MN)
Number of years living in current county: *
Cell Phone *
Home Phone
E-mail *
Name of Employer *
N/A if not employed
Names of other individuals living in the same household; if children, include their ages

Section 2B: Medical Hardship

Share information about the life threatening and/or incapacitating illness or injury that limits activities of daily living and has (or will) result in substantial out-of-pocket expenses of $5,000 or more.
Medical Diagnosis/Condition *

0/100
Date of Original Diagnosis *

- Month - Day Year
Anticipated Length of Treatment *
Health Insurance Carrier *
Have you applied for Medicaid/Disability? *

Yes No
How have treatment and medical expenses created financial hardship? *

0/500

Section 2C: Out-of-Pocket Expenses (NOT Covered by Insurance) Related to Medical Care and Treatment

Complete the table below identifying $5,000 or more of billed and/or estimated out-of-pocket expenses related to medical care and/or rehabilitation. Only note amounts the individual/family is liable for such as medical bills and prescriptions not covered by insurance, monthly premium expenses, travel & lodging costs for out-of-area care (may include companion), etc.

NOTE: Billed and/or paid medical expenses may be determined by requesting report(s) from clinic/hospital/pharmacy. Request a current balance and a self-paid total for the past 12 months. Future out-of-pocket expenses may be estimated based on treatment plans, copays, deductibles, coinsurance, etc. Contact your insurance company and/or the business office of the clinic/hospital for assistance.

Out-of-Pocket Expenses *

	Out-of-Pocket Expenses Past 12 Months	Estimated Out-of-Pocket Upcoming 12 Months
Medical Care (Provider, Lab, Radiology, Inpatient/Hospital)
Prescriptions/ Equipment/Supplies
Health Insurance - cost (if any) you pay to maintain coverage (Your premium/liability expense per month x number of months)
Travel/Gas (Based on $0.25/mile x number of miles x number of trips)
Lodging/Food (If you receive medical care out of area, estimate costs based on $125/person or $200/family x number of days there
Enter the total of the above five rows
(Optional) - Non-Medical Expenses Increasing Financial Hardship Due to Medical Condition and Lost Wages. Example: mortgage/rent, food, daycare, auto, etc.

Out-of-Pocket Expenses Spreadsheet *
If receiving out of area medical care, what facility and city? *
Who is responsible for payment of the above listed expenses? *
Have you received prior funding from Lend A Hand/Up? *

Yes No
If yes, when?

- Month - Day Year

Section 2D: Recipient Signature
REMINDER: Don't forget to mail, email, drop off or fax:
- Documents verifying local residency, name, age (photo ID or birth certificate)
- Documents verifying medical diagnosis/condition and provider (letter from doctor or discharge statement).
- Optional- Summary report verifying total paid and/or billed for the past 12 months for the medical institute, pharmacy, etc. (please do not send individual billing statements)
If a Lend A Hand Up representative has not confirmed that your application was received within 3 days of submission, please contact the program office.

Staff:
Jeana Peinovich, Lend A Hand Up Director
(701) 356-2661, jpeinovich@dakmed.org
Heather Hanson, Lend A Hand Up Coordinator
(701) 356-3138, heatherhanson@dakmed.org

Address:
4141 28th Ave S, Fargo, ND 58104

Fax:
(701) 271-0408
Signature *
Full Name
Date *

- Month - Day Year
Should be Empty: