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Update

Update as of March 28th, 2024

Since its inception in 2020 amidst the challenges of the COVID-19 pandemic, the Emergency Assistance Fund has been a beacon of hope for many individuals facing financial hardships. Originally designed as a temporary program to aid patients navigating the complexities of the pandemic, we have been privileged to extend lifesaving support to 448 transplant recipients totaling over $300,000 over the past four years.

In 2024, we have seen a 30% increase in applications compared to this time last year. Due to an overwhelming response and the prolonged duration of the program, we have fully utilized the available resources allocated for the Transplant Recipient Emergency Assistance Grant. Consequently, we are unable to accept new applications at this time.

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 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.

While we are unable to offer assistance through the Patient Assistance Program, 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
Important Details
Patient Information
Research Questions
Transplant Information
Employment History
Financial Information
Crisis Information
Alternate Funding
Insurance Information
Vendor Information
Transplant Center Information
Disclaimer

Social Worker

All Patient Assistance Program applications must be submitted by a social worker or transplant coordinator to be considered for grant funding. Applications submitted by the patient are automatically denied.

I am a transplant program social worker or coordinator completing an emergency fund application for a transplant recipient. Applications submitted by patient are denied automatically. *

I have thoroughly read and understand application guidelines *

Applicant Type

Transplant Center Orientation

A 10-15 minute orientation must be completed by your center's Transplant Administrator or similar supervisory role (NOT a Transplant Social Worker) before patients can receive funding. Please email support@americantransplantfoundation.org to see if your Transplant Administrator has already completed it to expedite the funding process.

I understand that my Transplant Administrator must complete an orientation before funds can be distributed. *

Address Verification

Please ensure all details in this application are correct; especially the patient's name and address. Funds will be sent directly to the patient and any incorrect details will lead to the check being returned and unable to be reissued.

I will verify with the patient that all details in this application are correct. *

Supplemental Documentation

Due to an extremely high volume of applications, we strongly recommend a letter or video from the patient describing the need for this grant. You can also have them email us their letter or video to support@americantransplantfoundation.org.

Patient Describing Need (optional but STRONGLY encouraged)

Patient Information

Patient First Name *

Patient Last Name *

Guardian Name - if patient is a minor

Patient Primary Phone Number *

Patient Secondary Phone Number

Patient Email *

Funds will be sent directly to the patient if approved. Please double check the patient's address is correct in its entirety, including unit number if applicable. We won't be able to reissue the check once it is sent out.

Patient Address *

Is the Patient Interested in Receiving Funds through Zelle if Approved (1-2 weeks Faster)? Only select yes if the patient has an existing Zelle account. NOTE: Providing this information does not guarantee that payment will be sent via Zelle. Payment may still be sent via check.

What is Zelle?

Payment Preferences

Is the account affiliated with their phone number or email address?

Zelle Phone Number

ext.

Re-Type Zelle Phone Number

ext.

Zelle Email Address

Re-Type Zelle Email Address

Research Questions

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 *

Transplant Information

Type of Transplant (Select all that apply)

Kidney

Liver

Pancreas

Heart

Lung

Intestine

Surgery Date *

On a scale of 1 to 5, how influential will this financial assistance be in order for the patient to maintain their transplant? *

Employment History

Is the patient currently employed?

Job Title

While employed, what is the patient's monthly income? *

Does the patient have short term disability benefits? *

Short Term Disability Percentage (per week)

Will the patient receive any paid time off? *

If yes, what percentage of their monthly income will they receive?

Last Date of Employment *

Reason for Unemployment

What is the patient's plan to cover monthy expenses?

Financial Information

NOTE: If patient will not be receiving any income at the time this application is submitted or afterward, please indicate that in the income section below. Please also include all monthly expenses the patient currently has.

Is the patient the head of the household? *

Partner or spouse in household? *

Number of Dependents (do not include patient or spouse) *

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 *

Household Income:

Current Monthly Household Wages Contributed by Patient (after taxes)
Note: put '0' if no current income *

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

Household Expenses:

Monthly Mortgage/Rent *

Other Household Monthly Living Expenses *

Monthly Insurance and Medical Costs *

Monthly Cost of Post-Transplant Medications Covered by Patient *

Total Household Monthly Expenses

$0.00

Please clarify any details regarding the patient's current and future financial situation

Crisis Information

Explain the patient's financial crisis in detail and how it is directly impacting their post-transplant care, family, or any other concerns the patient has regarding the crisis. (No minimum word count is required; however, successful applicants tend to give 4-5 sentences of explanation.) *

What has the patient done to address this crisis? (please describe in detail the current actions and plan moving forward) *

Amount Requested (Max grant is $500) *

What would this financial assistance mean to the patient? *

Is the patient at risk of losing their transplant without this grant? *

Please explain.

Without this grant, would the patient's health be in jeopardy? *

Please explain.

The patient will be willing to share how these funds have helped them. *

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.

Alternate Funding

Does your transplant center or its foundation have any financial assistance programs that this patient will be applying for? *

Please explain, why are you applying for this grant?

Is the patient receiving, or has applied for, financial assistance from another organization? *

From what organization will they receive funding and how much? Please explain.

Insurance Information

Medicare

Medicaid

Private Insurance

Name of Insurance Company

Vendor Information

The vendor listed on your application may either be patient's landlord's information, or other essential services/costs this grant will be able to cover.

Vendor Name *

Vendor Address *

Contact Phone *

ext.

Amount Requested Vendor *

Total Amount Owed *

Type of Expense *

What type of expense?

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

Vendor 2 Information

Vendor Name 2

Vendor Address 2

Contact Phone 2

ext.

Amount Requested Vendor 2

Type of Expense 2

What type of expense?

Total Amount Owed 2

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

Vendor 3 Information

Vendor Name 3

Vendor Address 3

Contact Phone 3

ext.

Amount Requested Vendor 3

Type of Expense 3

What type of expense?

Total Amount Owed 3

Transplant Center Information

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

Please Explain:

State Tx Center is located *

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 *

Transplant Administrator First Name *

Transplant Administrator Last Name *

Transplant Administrator Email *

Transplant Admin Phone Number *

ext.

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.

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

Disclaimer

I understand that my Transplant Administrator or similar role (NOT a Transplant Social Worker) must complete a 10-15 minute orientation in order for the funds to be dispersed if approved. Please contact support@americantransplantfoundation.org to confirm this has been completed and/or to schedule.

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, emergency financial assistance is based upon the sole discretion of the American Transplant Foundation and is subject to the availability of funds. All disbursements will be made directly to the patient. Failure to complete this application in its entirety results in automatic denial.

Yes, I agree *

After submitting, you will receive a confirmation email from support@americantransplantfoundation.org. Please open this email and add the address to your "Safe Senders" list to ensure you'll receive application status updates and important next steps.

I have added support@americantransplantfoundation.org to my contacts/safe senders

Signature *

Date of Signature *

To submit your application, please click the green save button at the top right corner of your screen. By submitting this application, you consent to the American Transplant Foundation contacting you and your patient in the future, when need be.

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