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National Gaucher CARE Foundation, Inc.
2021 CARE and CARE+PLUS Program Application
Patient Information










Patient Email/Phone Number






Applicants whose Federal Poverty Level is above 400%, do not meet the eligibility criteria. Thank you for your interest in the CARE Programs.




Legal Guardian's Phone Number 






Thank you for your interest in CARE. These programs are available SOLELY for US Citizens residing in the continental US. Please contact the International Gaucher Alliance, https://gaucheralliance.org/
Financially Responsible Party #1 (FRP1)















Phone Number





Financially Responsible Party #2 (FRP2) (2-income family only)















Phone Number




Page 2

All fields are required. Please enter 0 if there is no applicable amount.
Gross Monthly Family Income

$

$

$

$

$

$

$

$

$

$

Financial Information
Assets

$
line 8b on 2019 1040 income tax return OR, if receiving Social Security, benefit amount. If the Adjusted Gross Income is 0, please enter 0.

$

$
Monthly Liabilities

$
Credit Cards

$

$

$

$

$

$

$

$
Signature Loans

$

$

$
Utilities

$

$

$

$

$

$

$

Other Monthly Expenses (Please indicate the type of expenses in the Comment section in the next page)

$

$

$

$

$

$

$

$
Supplemental Financial
















COVID-19

























Page 3

CARE Request for Assistance - Insurance Premiums


Primary

If you and your spouse are included in one family policy, please complete only the family section.

Primary - Patient









Primary - Spouse









Primary - Family









Secondary

If you and your spouse are included in one family policy, please complete only the family section.

Secondary - Patient









Secondary - Spouse









Secondary - Family









Pharmacy

If you and your spouse are included in one family policy, please complete only the family section.

Pharmacy - Patient









Pharmacy - Spouse









Pharmacy - Family









Dental

Dental - Patient









Dental - Family









Vision

If you and your spouse are included in one family policy, please complete only the family section.
Vision - Patient









Vision - Family









Other

If you and your spouse are included in one family policy, please complete only the family section.

Other - Patient









Other - Spouse









Other - Family









CARE+PLUS Request for Assistance Only for Expenses Not Covered by Insurance





Travel Expense Details



Page 4

General Verification Documents
IMPORTANT! This application can not be considered without the Foundation receiving, either electronically or by mail, ALL of the following required documents:

- 2019 1040 or, if no taxes are filed, 2020 Social Security 1099 form. 

- Proof of Insurance (see requirement details below for those applying for a CARE grant)

- Waiver & Release of Liability - Download Form

- Medical Statement of Need (Only required for NEW Applicants) - Download Form

- Applicants whose Federal Poverty Level is between 300% - 400%, are required to provide verifying documentation to demonstrate extraordinary financial hardship beyond income.

Only PDF documents can be accepted.

Mail Details
AS OF MARCH 19, 2020 NO DOCUMENTS CAN BE ACCEPTED VIA MAIL. PLEASE UPLOAD ALL DOCUMENTS TO THIS APPLICATION.
If you are unable to upload your documents due to an extenuating circumstance, please send an email to care@gaucherdisease.org or call 301-900-1053.

NOTE: Your application is not complete and will not be submitted for consideration until all required documentation is received. Please ensure you 'SAVE' this application by clicking on the link at the bottom of the page. The NGCF will notify you once your documentation is received and attached to the application. Once notified, you will need to return to your application to review, certify and submit it.

Please read carefully as applications without the proper Proof of Insurance (POI) attached will not be considered. 


It is the applicants responsibility to provide the appropriate required documentation. 


If you have questions, please email, care@gaucherdisease.org, or call, 301-900-1053, prior to submitting your application.


Proof of Insurance is:


      IF APPLYING FOR THE UPCOMING CALENDAR YEAR (i.e. in November of current

      calendar year for a grant beginning January 1 of the upcoming calendar year):


      FOR PRIVATELY PAID INSURANCE PLANS:

·        A copy of your notification from your insurance carrier(s) regarding your UPCOMING calendar year insurance premium cost AND policy calendar year, i.e. January 1 - December 31 OR July 1 - June 30, etc.

FOR MEDICARE INSURANCE PLANS: 

·        A copy of your UPCOMING CALENDAR YEAR Medicare benefit rates. Medicare benefit rates are often slow to be mailed. You can check online through the Social Security Administration portal to obtain your deduction amounts.

FOR EMPLOYER SPONSORED PLANS: 

·         A copy of your most current pay stub indicating the cost of your insurance deductions AND

      • A verifying document from HR, such as a benefit table with your selected levels highlighted, as to your monthly group premium rates. Please ensure this table accurately reflects the premium rates for the UPCOMING calendar year as well as an indication of the policy calendar year dates, i.e. June 1 - May 30.


IF APPLYING AFTER JANUARY 1 FOR THE CURRENT CALENDAR YEAR:

    
     FOR PRIVATELY PAID INSURANCE PLANS:
  • A copy of your most current invoice from your insurance carrier(s) indicating your insurance premium cost AND policy calendar year, i.e. January 1 - December 31. This can be submitted as two separate documents if needed. 
    FOR MEDICARE INSURANCE PLANS:
  • A copy of your current calendar year Medicare benefit rate(s) letter. 
    FOR EMPLOYER SPONSORED PLANS:
  • A copy of your most current pay stub indicating the cost of your insurance 
      AND 
  • A verifying document from HR, such as a benefit table with your selected levels highlighted, as to your monthly group premium rates as well as the policy calendar year dates, i.e. June 1 - May 31.
YOUR INSURANCE POLICY CALENDAR YEAR IS REQUIRED AS PART OF THE VERIFYING DOCUMENTATION
    
If you are completing the application prior to January 1 for the upcoming calendar year, it is your responsibility to ensure the proof of insurance you are providing accurately reflects the 2021 premium for each policy. 

If your policy effective year is not January 1 - December 31, you must also provide documentation that verifies the policy calendar year, i.e. the letter last received by the health insurance carrier informing you of your premium rate as well as the effective date of the premium change. 






Comments

Certification



All information provided by an applicant will be held in the strictest confidence and is the sole property of the NGF/NGCF, its staff and its advisory board. No information provided to the NGF/NGCF will be released to any other organization or entity unless the applicant signs an appropriate release of information.

Please keep copies of all correspondence sent to the NGF/NGCF including the application, financial statements and any other documents provided to the NGF/NGCF.

Grants requests are only considered for complete applications (see above requirements re: verifying documentation). The CARE grant calendar cycle is December - November as monthly CARE grants are disbursed the month prior, i.e. January grant checks are disbursed in December. Approved grant requests after the December deadline in any calendar year, will commence with the CARE grant disbursement the following month and, therefore, will not be a full 12 month grant cycle. 

Please note that it is possible for grant requests made by qualified applicants to be denied due to request exceeding available funds. This application in no way guarantees the receipt of or entitles the applicants to requested grant funds.