Application for Matching Funds
Part 2
Information about Medical Hardship
To be completed by the individual or guardian who will receive proceeds from the fundraising effort. Part 2 information should be submitted in coordination with Part 1 (lead volunteer information about event and benefit fund).
Application Deadline: Applications are due by the first and third Monday of each month for a fundraising event scheduled in a following month - at least 30 days prior event and before information/flyer is publicy shared.
You must have the following information available before beginning the application process.If you have questions about required information and guidelines, please contact the program office: 701-356-2661 or jeanapeinovich@dakmed.org.
_____1- Information about child or adult experiencing a life threatening and/or incapacitating illness or injury that limits activities of daily living and results in substantial out-of-pocket expenses of $5,000 or more.
_____2- Out of pocket (non-covered) expenses related to medical care and treatment for each of the following categories:
Medical Care
Prescription/Medications
Equipment and Supplies
Health coverage premiums
Non-medical expenses creating hardship due to medical condition
Travel/gas/Lodging/Food
Past expenses may be determined by requesting a report from a clinic/hospital or pharmacy showing your self-paid total for the past 12 months. Future expenses may be estimated based on treatment plans, deductibles, co pays and coinsurance. Contact your insurance company and/or the customer service department of the clinic/hospital for assistance.
_____3- Documents verifying legal residency, name, age, medical diagnosis/condition and provider. Optional: statement verifying total expenses paid or billed as non-covered.
_____4- Recipient Signature
If you'd prefer to print and complete an application manually, do not use this form, instead go to part 2 at http://www.dakmed.org/wp-content/uploads/2014/08/LAH-benefit-Application.pdf.