Grant Application Questionnaire

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 ( 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

  1. Name, Address & Phone Numbers (home, work & cell), Relationship to patient
  2. Email address – (This will be the primary means for communication from/to ACD. Please make sure this email is one that is checked frequently)
  3. Patient’s Information

  4. Name, Address & Phone Number
  5. Social Security Number
  6. Date of Birth – (Must be 16 years of age or under to apply)
  7. Gender
  8. First time ACD grant applicant?
  9. Received a previous grant from ACD?
  10. Have others in the immediate family received an ACD grant?
  11. Insurance Information (Commercial health insurance is required to apply)

  12. Name of child’s health insurance company
  13. Health insurance member number – (member number, member ID, Policy number, etc.)
  14. Health insurance company phone number
  15. First and last name of the person who carries the health insurance and applicants’ relationship to the patient.
  16. Does the person above have the health insurance through full-time or part-time employment?
  17. Is the patient’s health insurance provided by the city, county, state or federal government?
  18. If yes, please describe.
  19. Does the patient have Medicaid coverage? Primary or secondary?
  20. If secondary Medicaid coverage, is this coverage due to the child’s medical condition?
  21. Does the commercial insurance coverage have an individual deductible?
  22. If yes, enter in whole dollars.
  23. Medical Information

  24. Brief description of the medical information/condition of the child this medical item?
  25. If No, please explain why the patient is not currently receiving services for this medical item.
  26. Are you going out of your health insurance company’s network for any of these services?
  27. If yes, please describe.
  28. 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?
  29. Please list the organizations, if request is pending, approved or not approved.
  30. Would your out-of-pocket cost, after insurance, be best categorized as a onetime only cost or a monthly cost or annual cost?
  31. 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?
  32. Doctor Information

  33. Child’s Primary Doctor Name, Address, Phone Number & Name of Clinic or Facility
  34. Other Information

  35. Number of people living in household as stated on Federal Tax Return

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Next Grant Application DEADLINE December 31, 2015