Get Safety Net Program Application - American Kidney Fund

Completing the Safety Net Program Application is an essential step for individuals seeking financial assistance for kidney-related needs. This guide provides step-by-step instructions to ensure users can fill out the application accurately and confidently online.

Follow the steps to successfully complete the application.

1. To begin, select the ‘Get Form’ button to access the application form and make it available in your online editing tool.
2. Fill in Part 1, which requests dialysis center information. Include the facility name, number, corporate affiliation, street address, city, state, zip code, phone number, fax number, renal professional contact's name, and email address. Ensure all fields are completed accurately.
3. In Part 2, provide your personal information. This includes your Social Security number, date of birth, name, mailing address, and phone number. Additionally, indicate your gender and email address.
4. Part 3 asks for additional information regarding your diagnosis and other confidential details. Fill this out carefully and decide whether to disclose your name and contact information for research purposes.
5. In Part 4, complete the patient financial information section. Report household assets, monthly income, and expenses. Be thorough and precise to ensure accurate evaluation of your financial status.
6. Proceed to Part 5, where you will request assistance and indicate eligibility for various financial assistance sources. Be sure to check all applicable boxes and provide necessary explanations as outlined.
7. In Part 6, confirm your understanding of the terms and conditions, and provide the required signatures from both the patient and renal professional. Ensure that signatures are dated appropriately.
8. After completing the form, review all sections for accuracy. You can then save changes, download the completed form, print it, or share it as needed.

Complete your Safety Net Program Application online today to seek the financial assistance you need.