CEREBRAL PALSY KINETIC CONNECTIONS SPECIAL NEEDS FUND APPLICATION

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1 CEREBRAL PALSY KINETIC CONNECTIONS SPECIAL NEEDS FUND APPLICATION The purpose of Cerebral Palsy Kinetic Connection s Special Needs Fund is to provide assistance to individuals and families impacted by high medical costs and support services related to cerebral palsy that are not covered through private or public health insurance programs. Eligibility Criteria 1. The applicant must live or receive cerebral palsy related services in Maryland. 2. The applicant must be the primary legal caregiver/s or provider/s for a child, adolescent or adult with cerebral palsy or an adult individual with cerebral palsy. 3. The applicant or legal guardian must complete and sign the application. 4. Attached to the application must be dated copies of bills, invoices or receipts for expenditures or purchase orders for requested equipment or services not yet purchased and if applicable a health insurance explanation of benefits (EOB). Eligible Services and Equipment 1. Any orthopedic equipment such as braces, wheelchairs, walkers, home health services, and specialized equipment and services. An EOB is required from your health insurance company. 2. Incidental hospital costs incurred by the individual with cerebral palsy or their primary legal caregiver/s or provider/s will be covered at 50% of the total expense. These may include television rental, parking fees, transportation, tolls or automobile mileage to and from the hospital for visitation. Similar expenses for outpatient care are not covered. Confirmation may be requested. 3. Disposable diapers will be covered for 50% reimbursement if the child is over three years of age. 4. Diagnostic tests such as MRI s and x-rays related to orthopedic diagnosis and care. An EOB is required from your health insurance company. 5. Home modifications, assistive device equipment, respite care, home health services will be considered for eligibility, but, in addition to invoice or documentation of payment, a statement of need, signed by a physician or medical professional is required. 6. Prescription medication related to cerebral palsy. Additional documentation may be requested to indicate how the prescription relates to cerebral palsy. An EOB from your health insurance or copy of the co-pay from the pharmacy is required. 7. Physician/surgeon charges for the diagnosis and treatment of cerebral palsy related medical care. An EOB from your health insurance company is required. 8. Any non-medical expense that assists the person with cerebral palsy socially, physically, or educationally will be considered and reimbursed at 50% up to the maximum allowed amount. 9. Camp and recreation program fees are eligible and covered at 100% up to the maximum allowed amount. 10. Non-insured dental care expenses are eligible and covered at 100% up to the maximum allowed amount. 11. All reimbursement checks will be made payable to the vendor unless proof of payment is shown. Receipt and cancelled check required. 4/12

2 PHYSICIANS/SURGEONS CHARGES DATE PHYSICIANS/DIAGNOSIS COST INSURANCE DIFFERENCE TOTAL PHYSICIANS/SURGEONS REQUESTED PRESCRIPTION MEDICATIONS DATE PRESCRIPTION/TREATMENT COST INSURANCE DIFFERENCE TOTAL PRESCRIPTION MEDICATIONS REQUESTED URINARY NOTE: Disposable diapers such as Pampers are reimbursed at 50% of the cost after insurance payment if the child is 3 years old or older. Receipts are needed for each item. Please do not send receipts in for one month and then multiply by 12 months. Only the receipts you attach to this application will be considered. The same is true for other urinary supplies used on a regular basis. If disposable diapers are not covered by you insurance, please send the company s rejection of your claim or a photocopy from your insurance booklet showing their exclusion. Some companies cover diapers, others do not. Proof of payment or rejection must accompany this application. DATE ITEM COST INSURANCE DIFFERENCE TOTAL AMOUNT REQUESTED (If Pampers, etc.) 50% REQUESTED DENTAL CARE DATE PROCEDURE COST INSURANCE DIFFERENCE TOTAL AMOUNT REQUESTED $

3 INCIDENTAL HOSPITAL COSTS Person hospitalized Date of Birth Hospital City State Dates of hospitalization: from to Total days hospitalized Transportation (specify) $ cost/day x days = $ Parking fees $ cost/day x days = $ TV Rental $ cost/day x days = $ TOTAL EXPENSES: $ Rebate is 50% of above total $ Auto mileage miles/day x days $.51/mile = $ TOTAL IN-HOSPITAL REBATE REQUESTED $ ORTHOPEDIC EQUIPMENT DATE ORTHOPEDIC EQUIPMENT COST INSURANCE DIFFERENCE TOTAL ORTHOPEDIC EQUIPMENT REBATE REQUESTED DIAGNOSTIC TESTS DATE DIAGNOSTIC TESTS COST INSURANCE DIFFERENCE TOTAL DIAGNOSTIC TEST REBATE REQUESTED HOME MODIFICATIONS/ASSISTIVE DEVICES DATE SERVICE COST INSURANCE DIFFERENCE TOTAL ADAPTATIONS/ASSISTIVE DEVICES REQUESTED

4 RESPITE CARE DATE PROVIDER FEE INSURANCE DIFFERENCE TOTAL REQUESTED: $ HOME HEALTH SERVICES DATE PROVIDER FEE INSURANCE DIFFERENCE TOTAL REQUESTED: _ CAMP/RECREATION PROGRAM DATE CAMP/RECREATION PROGRAM FEE TOTAL REQUESTED: $ NON-MEDICAL EXPENSE DATE SERVICE/PROGRAM FEE TOTAL REQUESTED: Rebate is 50% of above:

5 Timeframe for Submission and Awards of Assistance 1. Expenses submitted must be dated for the current year. 2. Requests for assistance with complete documentation will be reviewed quarterly and must be received by: March 15 th, June 15 th, September 15 th, and December 15 th. Applicants will be notified and, if assistance is awarded, will receive reimbursement within 30 days of review of application. Application Review Process Decisions on the approval of assistance will be made by a Cerebral Palsy Kinetic Connections Special Needs Fund Review Committee with the following representatives: an adult with cerebral palsy, parent of an individual with cerebral palsy, a medical professional familiar with the needs of a person with cerebral palsy, if possible, representative/s of organizations or individuals contributing to the Special Needs Fund. Assistance will not exceed $ and will be limited by the availability of resources in the Special Needs Fund. Please Print Name Telephone _( ) Address City State Zip Code County Name of Recipient Age Date of Birth Insurance Company Telephone _ ( ) Policy Number I have attached copies of actual bills/invoices or purchase orders for expenses submitted. I have included a statement of need from a physician or medical professional. I certify: (a) that these expenses are related to the care and treatment of cerebral palsy (b) that these expenses were not paid by any other source; and (c) that all the information contained on this application is true. (d) that I am the primary legal caregiver/s or provider/s for a child, adolescent or adult with cerebral palsy or an adult individual with cerebral palsy Signature of Applicant Date Mail this application and documentation to: Toni Shumate Cerebral Palsy Kinetic Connections Kennedy Krieger Institute 801 North Broadway, 5 th Floor Baltimore, MD (phone)/ (fax)

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