The mission statement of JoshProvides Epilepsy Assistance Foundation (“JoshProvides Foundation” or “Foundation”) is to educate, increase awareness, and provide financial assistance for people living with epilepsy and seizure disorders and their families. The Foundation strives to eliminate the negative stigma that is associated with epilepsy. The Foundation’s Charitable Purposes include:
(A) providing financial assistance for those people living with epilepsy and other seizure disorders and their families who are in need of help to pay for all or a portion of the expenses they incur for:
- transportation expenses to and from home, school, medical services and employment, through the purchase from or through third parties of gas cards, bus passes, taxi cab cards, or other third party transit options;
- the purchase of:
- prescription medication;
- medical services;
- seizure response/detection dogs;
- seizure detection devices,
- epilepsy research; and
- other technologies, methods, and devices
- which are recommended by the patient’s medical doctor and are not covered by private medical insurance, other reimbursement plans, or government-funded programs, i.e. Medicaid benefits and Medicare benefits (but not insurance premiums); and
- such other expenses which are within the spirit of the Foundation’s charitable purposes relating to such person’s health and care as approved from time to time by the Foundation and its Assistance Review Committee;
(B) assisting in the establishment and maintenance of strategic support groups for people living with epilepsy and their families; and
(C) paying for expenses incurred for educating the general public regarding epilepsy and seizure disorders (each of Sub-items (A) through (C) a “Qualified Service/Item”).
The Foundation has established certain procedures and guidelines for requesting financial assistance for a Qualified Service/Item by executing a Request for Financial Assistance Application described below (“Request Application”). A recipient acknowledges that the distribution of financial assistance is entirely discretionary by the Foundation. There is no assurance that a request will be approved in whole or in part or not at all within the sole discretion of the Foundation. A request in one instance shall not be considered the basis for approval or denial in a subsequent request for financial assistance. For purposes hereof, an applicant is a medical provider, pharmacy, not-for-profit organization, or other recognized public agency acting on behalf of a patient (each an “Applicant”).
These are the minimum guidelines an Applicant and patient must satisfy in order to be considered for financial assistance:
Eligibility Determination: To determine eligibility for assistance from the Foundation, the Applicant and patient must meet the following minimum standards:
- Applicant must describe in detail: (a) the amount requested; and, (b) the use of the funds.
- Applicant must certify that the Qualified Service/Item is necessary for the patient to monitor, control and/or reduce seizures.
- If applicable, Applicant must certify that the patient has no means of transportation to and from home, school, work, or medical services without using public or private transportation services.
- If applicable, Applicant, patient and manufacturer of any device must certify that the device is necessary for the patient to monitor, control and/or reduce seizures.
- If applicable, Applicant and patient who desire to organize a support group must attach to their Application for Financial Assistance a budget and plan of organization for review by the Foundation.
(B) Lack of Resources: Applicant and patient certify patient does not have sufficient resources to pay for the Qualified Service/Item:
- Patient has special circumstances that require financial assistance not available from any other source.
- Patient does not have or has insufficient coverage for Qualified Service/Item through private insurance or government-funded programs, including Medicaid benefits or Medicare Part D.
- Patient has insufficient income as demonstrated and certified by the patient and Applicant, due to being unemployed, suffering from a severe loss of income, or a lack of income.
- Patient has no other resources or means to pay for the patient’s Qualified Service/Item.
- Applicant and patient will certify to the Foundation that no portion of the funds will be used for administrative purposes.
- Applicant shall certify and acknowledge to the Foundation: it qualifies as an Applicant, is acting on behalf of the patient and is an advocate for the patient; no portion of the financial assistance will be used for administrative purposes; the patient’s request for financial assistance is a Qualified Service/Item and the financial assistance obtained will be used for a Qualified Service/Item. The Applicant and patient will further certify that:
- Foundation does not warrant or endorse any Qualified Service/Item requested by the Applicant and patient for the benefit of patient;
- Foundation is not the provider, manufacturer, distributor, agent, affiliate, owner, representative or consultant for any provider of a Qualified Service/Item;
- if a Request is approved, Foundation only provides financial assistance, in whole or in part, for a Qualified Service/Item and it is the sole responsibility of the Applicant and patient to communicate directly and consult with the provider of the Qualified Service/Item and the patient’s attending physician, to determine that the purpose and use of the Qualified Service/Item will be a benefit to and be in the best interest of the patient;
- Applicant’s and patient’s request for financial assistance is for a Qualified Service/Item;
- Applicant and patient have applied for one or more Qualified Service/Items after conducting their own due diligence regarding the use and benefit of the Qualified Service/Item for the patient without any endorsement or recommendation by Foundation; and
- Foundation has no responsibility or liability to or for the patient’s use or the benefit of any of the Qualified Service/Item. Applicant and patient assume all risks and consequences from the use of the Qualified Service/Item and release the Foundation and its board of directors, officers, sponsors, agents, employees, volunteers and affiliates from any responsibility and liability, of any kind or nature, whether foreseen or unforeseen, relating to patient’s use of or benefit received (or not) from the Qualified Service/Item. AN APPROVED “REQUEST FOR FINANCIAL ASSISTANCE” for A Qualified Service/Item SHALL BE MADE ON AN AS NEED BASIS AND DISTRIBUTED ONLY TO THE APPLICANT AND/OR PROVIDER OF THE QUALIFIED SERVICE/ITEM IDENTIFIED IN THE REQUEST OR THE APPLICANT’S DESIGNEE APPROVED BY THE FOUNDATION.
(D) Miscellaneous: Foundation reserves the right to approve or disapprove any request for assistance in whole or in part. The Applicant and patient will provide a photo of the patient and a testimonial and consent to the Foundation’s use of any and all photos and testimonials provided by the Applicant and patient on the website or otherwise without any further obligation to secure the Applicant’s and patient’s consent. All additional documents attached to the Application will be deemed incorporated in the Application.
Print the “Application for Financial Assistance” and any ancillary forms required by clicking the print button below and return the completed and executed Application either by mail or by pdf electonic transmission to:
JoshProvides Epilepsy Assistance Foundation, Inc.
ATTN: Bruce P. Chapnick
5428 Sundew Drive Sarasota, FL 34238
Phone: (800) 706-2740