Online Application

You will be required to attach all required documentation listed below directly to your application online prior to submitting. You may take pictures of your documents and attach images to your application if you choose. PLEASE NOTE: the application must be completed and submitted online. Please do NOT send us a copy of your completed application worksheet or paper documents.

Eligibility and Required Documentation

ACD board members and family are not eligible to apply for PatientStrong Grant funding. If applicant criteria are not met or if insufficient applications are received, the ACD reserves the right to hold grant funding until the next grant cycle. ACD reserves the right to change eligibility requirements each term.

Required Documentation:

As part of the online application questions, you will be required to attach certain required documentation to your application. The ACD recommends that you compile these documents and have them ready to submit prior to beginning the online application process.

The Documents your will be Required to Submit Include:

• Physician’s Certification of Medical Condition
• The first two (2) pages of your 2014 IRS 1040 tax filing that specifically lists the patient you are applying for as a dependent as well as you Adjusted Gross Income (AGI).
  • If the child was born after you filed, and therefore not listed on your IRS 1040, you will be required to submit a copy of the child’s birth certificate.
  • If the patient’s social security number is not listed on your IRS 1040, you will also need to attach a copy of their social security card.
  • If another parent/guardian claims the patient as dependent on their tax return, you will also be asked to attach a copy of that parent/legal guardian’s 2014 IRS 1040 tax filing.
• A copy of the front and back side of your primary health insurance ID card, or equivalent proof of commercial insurance coverage.
  • If the patient is covered by a secondary insurance plan, we will also ask that you attach a copy of that plan’s ID card or equivalent (ex: screen print of online account information listing insurance company, ID#, phone number, etc.)
  • If you have anything that your insurance company will not cover at all (0%), you will be required to provide proof. Proof can be a letter from your commercial health insurance company, or a copy of your benefits handbook that clearly states what is not covered, or an Explanation of Benefits (EOB), dated within the last sixty (60) days, that shows what item(s) is(are) not covered.
  • PLEASE NOTE: We may also request additional information from you after the application is submitted, or after receiving the required documentation outlined above. We also encourage you to attach other supporting documentation that you would like us or our Boards to consider as part of your application.

Grant Application are Received and Reviewed

In January, for February funding and;
In August, for September funding.

Grant Application