Patient Emergency Financial Aid Request

Patient Name

First

Last

Has patient received funds in the last 12 months.

Yes
No

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

Patient Age

Date

Name of Social Worker

Social Worker email

Dialysis Unit

Dialysis Unit Address

Address Line 1

Address Line 2

City

State

Zip Code

Amount Needed

Date Needed

Third Party Name

First

Last

Third Party Address

Address Line 1

Address Line 2

City

State

Zip Code

Need for assistance: (Receipts or statements required for any submitted invoices and repair requests)

File Upload

Click or drag a file to this area to upload.

The Patient Emergency Financial Aid Request Form must me filled out by a patient and all forms must be signed by the Patient.

Emergency Financial Aid Form

Housing

Utilities

Gas for Transportation

A $25 gas card from Casey’s will be sent to the Social Worker.

Explaination

If there is a specific reason the person is in need of more that $25 please explain.

Groceries

Medications

Not covered by Nebraska Renal, Medicaid, Medicare Part D or private insurance.

Transplant Patients

Necessary medical equipment

Other (please specify)

Details of circumstances regarding this request

Email

Mission Statement

Contact Details