Please answer the questions below to provide information regarding how your child's complex medical conditions have impacted family caregivers and finances in the past 24 months.
Please select the most applicable answers from the items below:
If you are applying for multiple children in your family please indicate below:
The next question relates to the out-of-pocket medical expenses incurred by the applicant during the last 24 months
Out-of-pocket medical expenses are defined as expenses for medical care incurred by the applicant.
Expenses include: insurance premiums, deductibles, coinsurance and copayments for covered services, plus costs for services that aren't covered by a primary insurance or all medical costs if the applicant does not have medical insurance. This may include the costs for medical equipment and supplies that aren't covered by insurance.
Examples include but are not limited to: cost of nutritional formula for applicants more than 2 years old, cost of incontinence supplies for applicants more than 3 years old and cost of other medically necessary medical equipment and supplies. Out-of-pocket expenses should not include the cost of home or vehicle modifications or items such as child car seats that would otherwise be required for the general safety of any child.
Self-attestation of out-of-pocket expenses may be subject to post-payment review and audit. In the event of an audit, applicants must be prepared to provide evidence to support the amount of out of pocket expenses claimed.
The next questions are related to how your child's complex medical conditions have impacted your family's employment experience.
Please Check ALL that Apply
The next question is used to identify the medical service coverage resources available to your child.
Please check the box below if your child has medical insurance coverage. If your child has medical insurance coverage please list the insurance providers below: