Connor James Smith Patient Assistance Grant
When establishing the grant program for families, we had one primary goal in mind: to make the process easy. We understand the mounds of paperwork and lengthy applications families are required to complete on an ongoing basis, and we wanted to make the process as seamless and quick as possible for them, helping to relieve some of their financial stress.Bereaved parents requesting financial assistance with burial costs are not required to fill out an application, instead please contact Kacie Craig directly (executivedirector@thecutesyndrome.com
Contact Information
SCN8A Patient's Name
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First Name
Last Name
SCN8A Patient's Date of Birth
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-
Month
-
Day
Year
Date
Applicant's Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Relationship to SCN8A Patient
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All applicants must be a member of TCSF SCN8A Families Support Group to be eligible for the grant program. Please contact Shelley Frappier (supportgroup@thecutesyndrome.com if you are unsure of your membership.
Is the Applicant a member of TCSF SCN8A Families Support Group?
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yes
no
unsure
Grant Request
Please explain what type of assistance you are requesting and how a grant would impact the SCN8A Patient.
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Please explain any financial barriers that prevent the purchase of the requested items/services/ Also include any assistance programs that you have pursued before applying for this grant or any additional financial assistance that you have secured to cover any costs above the $5,000 grant limit.
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Equipment/Items requested.
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Please provide the exact name of equipment/service, name of manufacturer or provider, and the name and contact information for the vendor. If available, please attach a brochure, photos, and/or provide a link to the purchasing website.
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Estimated Cost
*
Please research the cost of your items before submitting your application. If the estimated cost is above $5,000, please enter the amount you are requesting. An estimated cost must be included for your application to be considered.
Estimated Cost Documentation
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Please submit documentation of the expenses associated with your application. Attach a quote, bid, or invoice for the estimated cost.
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Physician/Healthcare Provider Professional Letter
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Please upload a recent (in the past 6 months) letter from the SCN8A Patient's physician or healthcare provider explaining the medical necessity of your request.
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Insurance Denial Letter
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Please upload a letter of denial from insurance provider stating the requested equipment and/or service was denied. If this is not possible to obtain or the patient requires the equipment/service quicker than the steps it would take to get insurance approval, please provide a written explaination.
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Reason No Insurance Denial Letter
Other Documentation
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Please upload any other documents pertaining to the nature of your request. All information will be kept confidential. Please note that any requests above $3,000 may require additional documentation.
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Submission
All boxed must be checked for application to be considered
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I understand that The Cute Syndrome Foundation is making no recommendation to the appropriateness or safety of any particular piece of equipment or therapy. TCSF and Board of Directors, selection committee, and co-funders Krista and Shawn Smith are not responsible for the safety and use of awarded equipment or therapies. Applicants are strongly encouraged to consult with their medical professionals and therapists regarding equipment and therapies that would be most beneficial for the situation.
I acknowledge that I have researched the equipment and/or services requested. I understand that once any items are approved and or ordered, they cannot be returned or exchanged for a different item.
I agree to submit a photo showing the SCN8A patient using the equipment or therapy that TCSF may use for advertising purposes of this grant program. Patients will only be identified by their first name and only with the consent of parents or legal guardians.
I agree to the terms and conditions that pertain to the grant program and all of the information entered is accurate to the best of my knowledge.
Please verify that you are human
*
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