2024 Dialysis Capacity Support Application
SUPPORT APPLICATION DISCLOSURES AND ACKNOWLEDGMENT SECTION
a. I grant Bridge of Life the rights to perform an individual and organizational background check.
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I understand and will comply with the support requirement.
b. Bridge of Life does not provide financial assistance or support for any pre or post center construction costs.
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I understand and will comply with the support requirement.
c. Bridge of Life does not provide financial assistance or support for shipping, customs duties, or importation taxes and fees.
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I understand and will comply with the support requirement.
d. Bridge of Life support resources cannot be used for individual or for-profit investment related ventures that could potentially benefit any investor in the form of compensation, shares, stock or profit returns to an individual, the organization or its officers.
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I understand and will comply with the support requirement.
e. A Bridge of Life onsite assessment will be performed prior to the final approval of all support applications. The cost of an onsite assessment shall be reimbursed to Bridge of Life upon the agreement with the applicant. IMPORTANT NOTE: The projected cost of the onsite assessment is $3000.00-$4000.00 (USD) and will cover the airline flight, visa, ground transportation, hotel accommodations, water testing and site assessment report and is non-refundable.
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I understand and will comply with the support requirement.
f. Bridge of Life requires partner investment from all organizations being supported by the dialysis capacity program due to the high hemodialysis center start-up cost. The hemodialysis center start-up cost will vary based size of the center or total patient station, Bridge of Life "DOES NOT" provide 100% capital and supply start-up cost so it is critical that support applicant have the adequate resources for a "minimum" of 40-50% of the start-up cost. The start-up cost will vary based on location and size, but a "general" or "average" start-up equipment and 6-month consumable supply cost will equate to approximately $12K-$14K per patient station.
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I understand and will comply with the support requirement.
g. The submission of my support application is not a guarantee that my support application will be approved and granted.
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I understand and will comply with the support requirement.
APPLICATION REVIEW PROCESS
This application is for consideration of inclusion in Bridge of Life's 2024 projects.
Support Applications must be submitted no later than 10/30/23 to be considered for 2024 support review.
All submitted applications will be reviewed on or before 12/30/23.
Final application site assessments will be conducted 1/1/24-2/29/24.
The final application approval decision will be completed 3/1/24.
Approved support projects for 2024 will need to begin and be completed no later than 3/1/25.
SECTION 1: ORGANZATION-INDIVIDUAL APPLICANT INFORMATION
Organization Legal Name
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Organization AKA or DBA name, if applicable
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Organization Mailing Address (Street, City, Zip Code, Country)
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Organization Website
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Country Where Center will be Located.
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Country Where your Organization is Based-Located
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Individual Mailing Address (Street, City, Zip Code, Country) if different from Organization
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Applicant Contact # (Include Area/Country Code
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Applicant E-mail
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Organization/Individual Office Phone
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Please include country Code
Organization/Individual Mobile Phone
Please include country Code
Country
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Country Where Center will be Located
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Center City Location
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Center Province Location (if applicable)
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Center District Location (if applicable)
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Have the Individual or Organization applied for Bridge of Life or any other project support in the past 5 years?
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Yes
No
If yes, please provide support details.
Please describe organizations hemodialysis center operational experience?
Have you partnered with Bridge of Life before?
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Yes
No
If yes, please provide details
SECTION 1a: ORGANIZATIONAL TAX STATUS
Organization Operational Status
Individually Own/Operated
Private
Public Private Partnership (PPP)
Non-Profit 501c (Complete 1-4 if non-profit)
Is your organization a 501(c)(2) nonprofit with valid EIN from the IRS (If yes, complete 1-3. If no, please move to next option)
Yes
No
1) EIN (Please type in the following format: XX-XXXXXXX)
2) Attach a copy of your organization's official notice of tax-exempt status from the IRS
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3) Attach a copy of your organization's current Board of Directors List
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Is your organization a congregation, governmental institution or accredited educational institution?
Yes
No
If Government Institution attach proof of affiliation (written verification from Federal, State or Local municipality of department/agency affiliation)
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If Government Institution attach staff or city/county board list
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If Congregation attach staff list or proof of affiliation
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If Educational Institution: Attach an administrative staff list for your institution.
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Were any grants or financial assistance provided to your organization for projects completed in the last 5 years by Bridge of Life or any other organization?
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Yes
No
If yes, please provide details to include date, scope of work and final outcomes/impact of activities.
Does your organization have any past or current experience managing hemodialysis center start-up or operations?
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Yes
No
If yes, please provide details to include date and location.
List the details to include locations of all hemodialysis or healthcare projects completed by your organization in the last 5 years.
Organization Core Services (100 Word Max)
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Organization Mission
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Please state mission and vision for the organization proposed dialysis clinic. List the impact this project will have on affected community?
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Total number Organization Staff Members
SECTION 2: UNDERSERVED LOCATION INFORMATION
What is the prevalence in your area of hypertension? (Please provide details and information source)
What is the prevalence in your area of diabetes? (Please provide details and information source)
What is the prevalence in your area of cardiovascular disease? (Please provide details and information source)
What is the prevalence in your area of kidney disease? (Please provide details and information source)
Describe in detail the current condition for renal failure patients in the area to be served?
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Do you know the number of current hemodialysis patients requiring treatment in the proposed area/location? Important Note: If you do not know or are unsure, you will need to research and provide an answer in order for your application to be reviewed.
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Yes
Current number of hemodialysis patients requiring treatments
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Provide the names and location of all chronic and acute hemodialysis centers located within a 200 mile/322 km range.
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Describe the area your clinic will serve (socioeconomic class, ethnicity):
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What are the native languages of the people you expect to serve?
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Please provide details regarding the patient referral process once the center is established.
How many patients do you estimate will receive chronic dialysis treatment per month?
How will patients be selected to receive dialysis treatment?
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Will there be a lab service available at the clinic?
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Yes
No
Does the Nephrologist practice medicine at other medical facilities?
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Yes
No
If yes, please list name and location
Please provide the per treatment total cost (USD) of one (1) dialysis treatment/session for the nearest public hemodialysis center/unit?
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Please provide the per treatment total cost (USD) of one (1) dialysis treatment/session for the nearest private hemodialysis center/unit?
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What will be the per dialysis treatment/session charged by your organization?
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Does your organization have plan for providing dialysis treatments for patients that cannot afford to pay for their treatment subsidized or treatment at zero cost?
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Yes
No
If yes, please provide details regarding how the program will be administered and the estimated subsidized treatment cost?
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SECTION 3: PROJECT DETAILS
Please indicate the type of support you are requesting Bridge of Life to provide.
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Equipment
Water System/RO
Dialysis Supplies
Reuse/Equipment and Supplies
Training
Other
Please describe why your community needs a dialysis program.
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Please provide details regarding how your proposed project will improve the current conditions and services in the area for patients suffering from chronic and acute kidney failure?
If the clinic already has a name, please provide.
Has a site been selected and finalized for the dialysis clinic?
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Yes
No
If yes, please attached the building drawing and photos.
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If yes, please provide details to include date, scope of work and final outcomes/impact of activities.
Do you anticipate needing to remodel the clinic or construct additional space for the dialysis clinic?
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Yes
No
What is the estimated date of completion of the new facility or remodel of existing space (if not already completed)?
Will the proposed center be a stand-alone or hospital-based hemodialysis center?
Hospital Base Center
Non-Hospital Base or Standalone Center
If hospital based, please provide hospital name and location details?
Will acute dialysis be provided?
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Yes
No
How many patients do you estimate will receive acute dialysis treatment per month?
Will the proposed center be located on property that is owned or leased?
Where will the funding for construction costs come from?
Have you enlisted the services of architect and engineer to evaluate the proposed site or location?
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Yes
No
If yes, please provide details.
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Please describe the current or anticipated electrical infrastructure at the medical facility (if applicable).
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Do you anticipate needing to make repairs or additions to the current electrical infrastructure in order to operate the dialysis clinic?
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Yes
No
If yes, please provide details.
SECTION 4: FINANCIAL DETAILS
Please provide detail regarding your "start-up" center patient census?
What will be your start-up and post start-up funding resource for the hemodialysis center?
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Will there be any government support of the dialysis program at your proposed dialysis center? (If yes, please describe in detail)
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How much funding per month do you anticipate receiving from government sources, per patient?
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Do you have any other funding sources for the operation of the dialysis clinic?
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Yes
No
If yes, how much funding per month do you anticipate receiving from other sources?
Is there a working plan for the dialysis clinic to obtain supplies needed for dialysis after the medical mission is complete.
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Yes
No
If yes, please explain and provide contact information if available.
Please provide details regarding all public and private reimbursement programs for patients suffering from renal failure.
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If no private or public reimbursement program is available, please explain in detail how patients will pay for their dialysis treatments?
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What licenses or certificates are required to open and operate a dialysis clinic in your country?
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Are there currently hemodialysis standards, regulations or requirement for the building and operating of Hemodialysis center?
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Yes
No
If yes, please attach/upload an English version of regulations.
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Have you already obtained the licenses, if required?
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Yes
No
If yes, please provide details.
Are there any local funding opportunities or groups that Bridge of Life could partner with to fund this project (NGOs, corporations, government, etc.)
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Yes
No
If yes, please provide details.
Location of sea container shipping port or ports
Are you aware of any local medical equipment regulations that would prevent or not allow the importation of remanufactured, used or refurbished equipment?
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Yes
No
If yes, please provide details.
Are you familiar with local laws and regulations to customs and importation of medical equipment and supplies?
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Yes
No
If yes, please provide details.
Have you ever imported any medical equipment and supplies for use in your clinic?
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Yes
No
If yes, please provide details.
Can remanufactured (refurbished) medical equipment be imported?
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Yes
No
If yes, please provide details.
Are you familiar with the process for getting a duty-free waiver for customs duties?
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Yes
No
If yes, please provide details to include all customs duties, tariffs and importation fee?
Do you have any partner organizations or affiliations with government officials that can help with the importation process?
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Yes
No
If yes, please provide details to include all customs duties, tariffs and importation fee.
Does your organizations have a freight forwarding agency to assist with the equipment and supply importation?
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Yes
No
If yes, please provide Name of company, contact person's name, email and phone number
SECTION 5: STAFFING AND TRAINING
Have you already selected experienced hemodialysis staff to work in the proposed dialysis clinic?
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Yes
No
If yes, please provide details.
Are local qualified doctors, nurses, and technician available to staff center?
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Yes
No
If yes, please provide details.
Approximately, how many people will participate in the start-up training?
Please describe all selected individual participants and their hemodialysis area of expertise, training, experience and certifications held (background, language, education level, etc.)
Have you contacted a local Nephrologist to provide Medical Director's support for the proposed dialysis clinic?
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How many years has the Nephrologist practiced?
How will the Nephrologist be compensated?
Telephone number of Nephrologist (Provide detail to include compensation for services rate if determined):
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E-mail of Nephrologist:
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Does the Nephrologist practice medicine at other medical facilities?
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Yes
No
If yes, please list name and location
Please provide any additional information and details that you believe may be useful in the understanding of your specific training needs.
Do you have nurses trained in dialysis?
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Yes
No
Other
Do you have a technician to repair, service and maintain machines?
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Yes
No
If yes, please provide details?
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Please describe any specific training needs for clinic staff
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SECTION 6: ADDITIONAL QUESTIONS
Please feel free to include any questions or information you want to share regarding your proposed project.
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Submit
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