PATIENT CARE PROGRAM

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1 PATIENT CARE PROGRAM OVERVIEW Does someone in your community need cataract surgery but not have the means to pay for it? Do you know of a deaf person that hasn t been able to use the telephone because an adaptive device is too expensive? Through Patient Care Grants, the Northeast Pennsylvania Lions Service Foundation (Foundation) partners with the Lions/Lion and Lioness/Lioness/Leo Clubs in our 37 county service areas to help low-income individuals get sight and hearing treatment that they otherwise cannot afford. We have funding to help your Club support the following types of projects, services, and/or treatments: Cataract surgeries FM systems Cornea transplants Hearing Aids Magnification equipment Sign language instruction Vision therapy Baby monitors for deaf parents Special glasses/contacts A hearing guide dog A guide dog Talking computer software Speech therapy for children with hearing loss The Process begins when a Club decides to sponsor someone and submits the attached application to us. The application is reviewed by our Grants Committee to determine if we are able to help. If approved, we pay half of the treatment cost and your Club pays the other half. If you have any questions, do not hesitate to contact the Foundation at or Thank you for the wonderful work you do for your community! 1 P age

2 Income Qualification Guidelines Based on 200% of the 2016 Federal Poverty Guidelines Size of 2016 Federal 200% of 2016 Federal Family Unit Poverty Level Poverty Level 1 $11,770 $23,540 2 $15,930 $31,860 3 $20,090 $50,225 Patient Care Instructions STEP 1: DECIDE TO SPONSOR A PATIENT The only eligibility requirements are that the applicant is 1) a resident of one of the 37 counties that the Foundation serves and 2) financially unable to pay for his/her own care through personal resources, health insurance, government assistance, or other social services. Because the treatments covered by Patient Care Grants can be expensive, we think of the program as a last resort for people in need and leave it up to each Club to decide how to screen patients-----e.g., your method may require proof of income, a list of attempts to obtain assistance through other sources, or a home visit. We ask that you obtain an estimate for the procedure or equipment. STEP 2: TALK TO THE SERVICE PROVIDER The starting point here will vary. In some cases, an applicant will already have a medical or product vendor prepared to offer services. In others, the applicant will need your help in identifying where to turn. Feel free to call us for advice we can provide you with a list of providers that other Clubs have used and may be able to help you negotiate a lower price. We also encourage you to seek out local sight and hearing professionals willing to offer a discount on their services. Do not be afraid to introduce yourself and explain how the Patient Care program works. Depending on the provider s line of business, this is a contact that can benefit your Club on many levels. In addition, make the provider aware that all bills will be sent to the Foundation. If multiple bills are necessary, the total amount of all bills may not exceed the grant amount. STEP 3: SUBMIT THE APPLICATION First, mail a Patient Care application to the Foundation before the patient is treated. Be sure to include a detailed explanation of the treatment and estimated cost and a letter describing why your Club is sponsoring the applicant. It is also helpful to attach supporting documents such as 2 P age

3 correspondence from the doctor, provider, or applicant, as well as a HIPPA form. Once we receive the application and attached documentation, we will forward the application to our Grants Committee for approval. In addition to determining whether the request meets our guidelines, the Committee will also help to ensure that you are getting the best price from a doctor or vendor. The Foundation endeavors to let you know of its decision by phone or within 3-5 business days. STEP 4: PAYMENT It is important to make sure that the provider sends all invoices to the Foundation after the surgery has been completed or the required item has been purchased. Note: some providers take longer than others to bill, so please follow up as necessary to prompt them. We will pay the provider up to the amount of the grant only, and then we will bill your Club for half. Once we have received your payment, we will send you a letter or confirming that the patient s file has been closed. 3 P age

4 PATIENT CARE APPLICATION Patient Information Patient Name Age If a minor, name of guardian Street address City, State, & Zip Patient or guardian s signature Date Treatment Information Professional diagnosis Recommended treatment (e.g., medical procedures, adaptive equipment) Estimated cost: ***Please attach details on the treatment and cost as necessary*** 4 P age

5 Name of Doctor (if applicable) Name of Organization Street address City, State, & Zip _( ) Telephone number **ATTACH SIGNED HIPPA FORM** CLUB INFORMATION: Name of Club submitting application Contact Lion Title Street address City, State, Zip Telephone number By signing below, we endorse this application and agree that our Club will abide by its terms. We also understand that the Northeast Pennsylvania Lions Service Foundation presents this program as charitable aid and that there is no implied or implicit guarantee of the quality of services or equipment associated with the program. We acknowledge that the Foundation cannot warrant or certify that the services or products provided by any provider meet any particular level of professional or industry standard. Signature of Lions Club President Date Telephone Signature of Lions Club Secretary Date Telephone Contact 5 P age

6 IMPORTANT: IN ORDER TO EXPEDITE THE PROCESSING OF YOUR APPLICATION, PLEASE MAKE SURE THAT EVERYTHING IS SIGNED AND ALL FORMS AND DOCUMENTS ARE ATTACHED AS REQUESTED. Make sure to keep a copy of everything for your Club records. PLEASE EITHER: MAIL APPLICATION TO: Patient Care Grant Northeast Pennsylvania Lions Service Foundation 2346 Jacksonville Road Bethlehem, Pa OR THE PACKET TO: 6 P age

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