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ALL STATUS UPDATES ARE SENT AUTOMATICALLY TO THE SOCIAL WORKER'S EMAIL. DUE TO HIGH VOLUME WE WILL NOT DIRECTLY RESPOND TO ANY INQUIRIES.

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As a non-profit organization, our program relies entirely on the generosity of our financial donors. We work tirelessly throughout the year to obtain individual donations for this program and don't receive any funding from the government or out of state transplant centers. Your support is crucial in enabling us to continue providing essential services to those in need.

We invite the opportunity to connect with you to further enhance the support available to patients in our community. Your contribution will ensure that your patients have the support they need to face the financial challenges of organ transplantation.

We remain committed to serving the transplant community through our other lifesaving programs.

We encourage you to explore our Financial Resource Guide, available in both English and Spanish, to explore alternative assistance programs that may be of help to you.

Together, we can continue to make a meaningful difference in the lives of transplant families.

Social Worker
Patient Information
Research Questions
Transplant Information
Employment Information
Financial Information
Patient's Insurance Information
Vendor 1 Information
Vendor 2 Information
Vendor 3 Information
Transplant Center Information
Alternate Funding
Disclaimer

All Patient Assistance Program applications must be submitted by a transplant social worker or transplant coordinator at least 2-3 weeks prior to the surgery date in order to be considered for grant funding.

I am a transplant social worker or transplant coordinator completing a Patient Assistance Program application for a living donor. Applications submitted by patient or out of state are denied automatically. *

I am submitting a required signed documentation from the patient's employer stating available paid time off and/or short term disability, and any employee assistance programs (see our website if questions) *

I've read the guidelines and understand that I need to submit the application at least 2-3 weeks before surgery and the patient needs to be employed. *

Patient First Name *

Patient Last Name *

Patient Primary Phone Number *

Patient Secondary Phone Number

Patient Email *

Funds are sent directly to the patient; please confirm with the patient that the address below is correct in its entirety and includes unit number if applicable.

Patient Address *

The following questions are required, but the answers will not affect the patient's eligibility to receive a Patient Assistance grant. Their answers help our foundation demonstrate the need to keep funding this program and may help us tailor assistance to transplant patients in the future.

Gender *

Date of Birth *

Patient Primary Language *

Race/Ethnicity *

Please mark all of the following that are true. For the patient, this grant would: *

Type of Transplant (Select all that apply)

Kidney

Liver

Lobe of the Lung

What type of living donor is the patient? *

Is this a paired exchange?

Recipient Relationship

What insurance does the recipient have? *

Please specify who this patient is donating to (father, wife, son, etc.)

Is this patient donating through the National Kidney Registry program? (Kidney donors only) *

Is this patient participating in a living donation chain? *

Surgery Date

Surgery date must be confirmed for your application to be considered. Please contact us if you have questions.

Reason for Referral *

Would the patient be able to donate without this grant? *

Ability to Donate Explanation

Letter or video from Patient Describing Need (optional but encouraged)

Within 3 months of receiving this funding, an update of how these funds have helped your patient will be required either by yourself or your patient. (Check box to agree) *

Please attach a photo of the patient if they provided one via their application guide. This is used for testimonials if the patient receives funding.

Current Employer *

Job Title *

Employment Full or Part Time *

Second Employer (If applicable)

Job Title

Secondary Employment Full or Part Time

Please upload required letter from the patient's employer - see our website for more details *

What is the patient's minimum required post-operative recovery time in weeks? *

Will the patient receive any short term disability? *

How long will the patient receive short term disability? (Specify number of weeks)

What percentage of their standard pay will they receive through short term disability during their recovery? (i.e. 20%, 10%, etc).

Will the patient receive any paid time off (excluding short term disability)? *

How much paid time off will the patient receive? (Specify the number of weeks)

What percentage of their standard pay will they receive during their recovery? (i.e. 20%, 10%, etc). *

Is the patient's spouse, as their recipient, employed?

Is the patient's spouse, receiving any paid time off?

How much paid time off will the patient's spouse receive? (Specify days or weeks)

What percentage of their standard pay will they receive during their recovery? (i.e. 20%, 10%, etc).

What is the patient's total estimated loss of wages during recovery (after taxes)?
i.e. If your patient will be out 2 weeks, won't receive time off, and their standard monthly pay is $4,000, please put $2,000. *

Amount Requested (Max grant is $500) *

Is the patient the head of the household? *

Partner or spouse in household? *

Number of Legal Dependents (Claimed on Taxes) *

Please list any legal dependents' ages

What is the total number of persons in the household? Please include the patient, any dependents, spouse, and any other family members living in the same household (siblings, grandparents, etc). *

Does the patient currently have a savings account? *

Amount in Savings *

Current Monthly Household Wages Contributed by Patient (after taxes) *

Monthly Household Wages Contributed by Others (after taxes)
*Please include any contributions regularly made to the household

Social Security Income

Disability Income

Total Net Household Monthly Income (after taxes)

$0.00

Monthly Mortgage/Rent *

Monthly Insurance and Medical Costs

Other Household Monthly Living Expenses *

*Other household expenses: include all essential living expenses such as food, transportation, phone, utilities, car insurance, etc.

Total Household Monthly Expenses

$0.00

Medicare

Medicaid

Private Insurance *

Name of Insurance Company

Vendor Name *

Contact Phone *

ext.

Amount Requested Vendor *

Total Amount Owed *

What type of expense? *

Please Explain:

Do you have a second vendor? Check box for yes.

Vendor Name 2

Please verify this is the vendor's BILLING ADDRESS. Returned checks will not be reissued.

Contact Phone 2

ext.

Amount Requested Vendor 2

Total Amount Owed 2

What type of expense? 2

Please Explain:

Do you have a third vendor? Check box for yes.

Vendor Name 3

Please verify this is the vendor's BILLING ADDRESS. Returned checks will not be reissued.

Contact Phone 3

ext.

Amount Requested Vendor 3

Total Amount Owed 3

What type of expense? 3

Please Explain:

If this is your first application, how did you hear about the Patient Assistance Program?

Please explain

Transplant Center Name: Please search and select the FULL name of your transplant center below. If you don't see yours listed, please choose "Other" and put it in the text box that will appear. *

Transplant Center - Please Use Complete Official Name

Social Worker First Name *

Social Worker Last Name *

Social Worker Phone *

ext.

Social Worker email *

I would like to receive periodic emails (usually quarterly) about the American Transplant Foundation s exciting events, programs, valuable resources, news, and inspiring patient testimonials.

Transplant Administrator First Name *

Transplant Administrator Last Name *

Transplant Administrator Email *

Transplant Administrator Phone Number

ext.

Orientation Status

Please review orientation status below. If marked "Not Completed", please reach out to support@americantransplantfoundation.org to schedule a time for your transplant administrator to complete it.

Center Orientation Completion Status

Does your Transplant Center or its Foundation provide funding for living donors? *

If so, please explain the patient's additional needs for this grant

Did the patient apply for financial assistance from any another organization(s)? *

Please explain which specific organizations the patient has applied to and how much financial assistance they have requested from each.

Has the patient been approved for financial assistance from another organization? *

Please provide the organization(s) name(s) and total amount approved by each organization.

Is the patient receiving financial assistance through the "Donor Shield" Program? *

I agree to report any additional financial assistance the patient will receive by the date of the surgery by emailing support@americantransplantfoundation.org.

Yes, I agree. *

I affirm the information provided to be true and accurate to the best of my knowledge. I understand that all applications are reviewed on a case-by-case basis, and that eligibility for one-time financial assistance is based upon the sole discretion of the American Transplant Foundation and is subject to the availability of funds.

Yes, I agree. *

I understand that all applications need to be submitted at least 2-3 weeks prior to the surgery and must include a letter from an employer stating available PTO balance, disability and employee assistance benefits the patient is eligible for. Failure to complete this application in its entirety within established deadlines results in automatic denial.

Yes, I agree. *

You will receive a confirmation email from support@americantransplantfoundation.org. Please add this address to your "Safe Senders" list to ensure you receive important application status updates.

Yes, I agree.

Signature *

Date of Signature *

To submit your application, please click on the green save button in the top right-hand corner of your screen.

By submitting this application, you consent to the American Transplant Foundation contacting you and your patient in the future, if need be.

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