Follow the steps to complete the application form.

1. Press the ‘Get Form’ button to obtain the application form, which you will need to fill out thoroughly.
2. Begin by entering the patient’s name and date of application at the top of the form. If the applicant is a minor, include the name of the parent or guardian.
3. Fill in the patient’s date of birth, age, gender, and complete address, ensuring all information is accurate.
4. Indicate the county of residence and specify ethnic origin for reporting purposes, though this section is optional.
5. Provide details about the patient’s diagnosis by checking all applicable conditions and their current mode of treatment.
6. In the financial information section, indicate whether the patient is employed, and list details about household income and expenses.
7. Complete the assessment section, requiring verification from a social worker or physician, to describe the patient's financial needs.
8. Once all necessary information is entered, review the application for completeness, ensuring no fields are left blank.
9. After confirming the application is complete and accurate, save your changes. You can also choose to download, print, or share the form as needed.

Complete your application for the OH Kidney Foundation Transportation Reimbursement Program online today!