The Second Wind Board of Directors is pleased to announce establishment of a Financial Assistance Fund to provide financial assistance for medical, drug, temporary housing, and emergency expenses incurred or to be incurred by a member of Second Wind which are directly related to pre or post-lung transplant care. A description of the program follows.
A Tradition of Service
The desire to be of assistance to pre and post-lung transplant patients and their families by providing support, advocacy, education, information and guidance through a spirit of service has long been the mission of Second Wind as witnessed through its slogan, “Support Through Service.” The difficulties that transplant patients experience as a result of ever-increasing costs of health care and associated expenses of transplantation clearly indicate that there may be a role for Second Wind to play with financial assistance in this area. Over the years requests have been received for financial assistance that range from prescriptions and air travel to temporary housing costs. Until now, the Association has never been in a financial position to help. The Association now has reached a level of membership and other support to be able to establish a Second Wind Financial Assistance Fund with limited annual funding.
The Second Wind Financial Assistance Fund is intended to be a charitable provider of limited financial assistance to members of Second Wind who are lung transplant patients at any accredited lung transplant center in the USA except Barnes-Jewish and St. Louis Children’s Hospitals in St. Louis, MO. (Note: St. Louis Second Wind, a chapter of Second Wind Lung Transplant Association, Inc., has a similar assistance program for patients at these centers). The program is designed to help pay for medical and other related expenses that are of an emergency or non-insured nature. There is a limit as to the level of assistance provided to each eligible applicant each year as well as an annual limit on the total assistance fund established and provided to all eligible applicants each year. Assistance will only be provided when funds are available. There are specific eligibility criteria and, once an application is received, an evaluation process will take place which will determine whether or not assistance will be provided and in what amount.
In order to apply for assistance an applicant must meet the following criteria:
- Be a member of Second Wind Lung Transplant Association, Inc.;
- Be a lung transplant patient at any accredited lung transplant center in the USA except St. Louis Children’s Hospital or Barnes-Jewish Hospital;
- Be either post lung transplant, on a waiting list for lung transplant or in the lung transplant evaluation process;
- Have a medical or other related need for financial assistance which is of an emergency or non-insured nature;
- Complete all sections of the Second Wind Financial Assistance Fund application. The applicant or guardian cannot have a total annual household income of more than $50,000.00. Extenuating circumstances, if any, should be listed; i.e., number of family members, costs of care, unemployment etc.;
- The application for assistance must be verified by the Social Worker, Financial Coordinator or Nurse Coordinator of the transplant team;
- All requested documentation must be submitted;
- The application must be accompanied by proof of all sources of household income. This can include tax statements, pay stubs, Social Security award or denial letter and other documents;
- If applying for a bill to be paid, a copy of the bill or formal cost estimate must be submitted with the application.
Distribution of Funds
Any distribution of funds will be made directly to a provider such as a pharmacy or temporary housing company. Amounts will be provided in specific quantities for specific purposes.
Donations of any nature to Second Wind Lung Transplant Association, Inc., are always welcome. With the establishment of the Assistance Fund, future donations may be designated exclusively to this Fund.
Funding for this Policy will be derived from general funds of the Association including any donations specifically designated to the Financial Assistance Fund, such donations being added to the annual funding limit established by the Board of Directors.
The Board of Directors of Second Wind is responsible for this Policy and will:
- Establish annual program funding at the start of each Program year; this limit will be $5000.00 in 2012 and will be reviewed annually;
- Fix limits of funds to be granted by individual grant, by annual amount to each applicant and for the lifetime of each applicant; these limits will be $500, $500 and $1,500, respectively, in 2012 and will be reviewed annually;
- Delegate implementation of this Policy to a Committee composed of a minimum of three (3) members of the Board of Directors.
To qualify for funding under this Policy, a Member must present valid evidence of need for legitimate related expenses as defined above. The Board of Directors of Second Wind in its sole discretion may change any aspect of this Policy or eliminate the Program entirely without prior notification.
Short Form: If your request is for $250.00 or less, proceed to the Short Form contained hereafter and complete it. You also must complete the Release Form and when you have completed the Short Form and the Release Form, mail them to the address at the bottom of each page of this application.
Long Form: Requests for more than $250.00 will require a Long Form contained hereafter. You also must complete the Release Form and when you have completed the Long Form and the Release Form, mail them to the address at the bottom of each page of this application.
Any distribution of funds will be in the form of a check made payable to the provider. Amounts will be for specific quantities and not general lump sums.
These guidelines are subject to change without notice and can be amended by Second Wind Lung Transplant Association, Inc. Incomplete applications may not be processed. The Second Wind Financial Assistance Fund reserves the right to deny requests for assistance. Funds will be distributed on a nondiscriminatory basis without regard to age, gender, race, religion, sexual orientation or ethnicity.
Please read the following instructions carefully for proper completion of the attached Financial Assistance Fund Application package. Please ensure that all required sections of the application are complete. The application may be returned and the request for assistance not considered until the application is complete.
- To begin, determine if you are requesting assistance in the amount of $250.00 or less (Short Form) or more than $250.00 (Long Form).
- The Patient or Guardian completes the appropriate sections of the application (Short or Long Form). Retain the instructions and guidelines and make a copy of the application for your records.
- Patient/Guardian must sign on the last page of the Short Form application and on the last page of the Long Form application, whichever application is being submitted. If using the Long Form application, a witness must also sign on the last page of the Long Form application. The Patient Release Form must also be signed by the Applicant and his/her signature must be witnessed and signed by the witness The Social Worker, Nurse Coordinator or Financial Coordinator must sign the Transplant Center Verification form.
- Upon completion of the appropriate sections of the application by the patient or their guardian, including the necessary signatures and witness signatures, forward the entire packet to the patient’s Social Worker, Nurse Coordinator or Financial Coordinator at the patient’s transplant center.
- After the designated member of your transplant team (listed in the paragraph above) has completed the Transplant Center Verification page of this packet, he/she will forward the entire package to:
Second Wind Lung Transplant Association, Inc.
3440 Halliday Avenue
St. Louis, MO 63118
Tom Archer, FAP Chairman
Following you will find the forms in the order in which they appeared above. You will need to complete either the short or the long form as well as all the other forms in order for your application to be complete.
Patient Application – Short Form (2 pages)
Patient Application – Long Form (3 pages)
Patient Release Form (1 page)
Transplant Center Verification Form (2 pages)
The Second Wind Board of Directors is extremely pleased with the establishment of the Financial Assistance Fund. Should you have any questions, please contact members of the 2012 Financial Assistance Fund Committee. Committee members are listed before for your convenience. The Board of Directors is excited to be in a position to offer this benefit to our membership and we hope that through continued support the program will grow each year.
Tom Archer, FAP Chairman – firstname.lastname@example.org
Cheryl Keeler – email@example.com
Garry Nichols – firstname.lastname@example.org
Steve Schumann – email@example.com
Gary Bland – firstname.lastname@example.org