Thank you for taking the time to collect information needed to complete an online application with the Association for Creatine Deficiencies’ PatientStrong Program. Please use this Worksheet as a guide to help you collect this information before starting your application.
All applications must be submitted through the ACD website (www.creatineinfo.org) under the PatientStrong Apply Now menu.
Please Note: Once you begin the online application, you will NOT be able to save and come back to it.
Parent/Legal Guardian Information
- Name, Address & Phone Numbers (home, work & cell), Relationship to patient
- Email address – (This will be the primary means for communication from/to ACD. Please make sure this email is one that is checked frequently)
- Name, Address & Phone Number
- Social Security Number
- Date of Birth – (Must be 16 years of age or under to apply)
- First time ACD grant applicant?
- Received a previous grant from ACD?
- Have others in the immediate family received an ACD grant?
Insurance Information (Commercial health insurance is required to apply)
- Name of child’s health insurance company
- Health insurance member number – (member number, member ID, Policy number, etc.)
- Health insurance company phone number
- First and last name of the person who carries the health insurance and applicants’ relationship to the patient.
- Does the person above have the health insurance through full-time or part-time employment?
- Is the patient’s health insurance provided by the city, county, state or federal government?
- If yes, please describe.
- Does the patient have Medicaid coverage? Primary or secondary?
- If secondary Medicaid coverage, is this coverage due to the child’s medical condition?
- Does the commercial insurance coverage have an individual deductible?
- If yes, enter in whole dollars.
- Brief description of the medical information/condition of the child this medical item?
- If No, please explain why the patient is not currently receiving services for this medical item.
- Are you going out of your health insurance company’s network for any of these services?
- If yes, please describe.
- Have you sought assistance to help with medical item(s)/service(s) in the past year from other public or private sources? For example, city, county, state organizations other charities?
- Please list the organizations, if request is pending, approved or not approved.
- Would your out-of-pocket cost, after insurance, be best categorized as a onetime only cost or a monthly cost or annual cost?
- Based on your choice above (one time cost, monthly cost, or annual cost), what is your estimated out of pocket cost, after insurance, in whole dollars for CDS medical expenses?
- Child’s Primary Doctor Name, Address, Phone Number & Name of Clinic or Facility
- Number of people living in household as stated on Federal Tax Return
Next Grant Application DEADLINE December 31, 2015