Financial Assistance Program – Application for Assistance

To complete the Financial Assistance Program (FAP) application, you must read the FAP Instructions for Application.

After you fill in the information below, click "Print Application" to create a PDF that you can sign and take to your dialysis provider so that he or she can complete your application.

* Required fields

Applicant Personal Information
  1. - -
Household Information
Applicant Financial Information
  1. Proof of Income and family size required: Proof of income and family size must be submitted with this application in order to determine financial assistance eligibility. If an income tax return cannot be provided, we will accept a W-2 statement.

    If you do not have income in a certain category, enter a zero.

  2. $
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Health Insurance Plan Details
  1. Those with private primary insurance under Medicare or a Medicare Advantage program are not eligible.

    Please provide below information about the coverage you receive under your current health care plan. This information will be used for tracking purposes only and will help the TRUST determine how the grant is being utilized during the pilot phase of this program.

Your completed and signed Application for Assistance must be mailed or faxed to the address/fax number below by the dialysis facility representative or the applicant's designated provider contact.

Financial Assistance Program - The Kidney TRUST
1350 Old Bayshore Highway, Suite 777
Burlingame, CA 94010
Fax: 1-720-223-2008