ALS Ice Bucket Challenge Progress

 

The North Carolina Chapter Grant Program assists North Carolina families with expenses that are not traditionally covered by insurance such as private insurance, Medicare, Medicaid and other assistance programs. It will cover, but is not limited to, home care assistance (respite), travel costs related to ALS clinics or research, home modifications, auto modifications, communication devices, environmental controls and generators for invasive or non-invasive breathing assistance. 

*PLEASE READ THIS BEFORE COMPLETING YOUR REQUEST *

→ TO BE ELIGIBLE FOR THIS GRANT, YOUR PRIMARY RESIDENCE MUST BE IN NORTH CAROLINA AND HAVE A VERIFIED DIAGNOSIS OF ALS

Important Information

  • This is a reimbursement grant program. Only items as stated on the ALS Eligible Expenses List, that you have already paid for during the current period, may be reimbursed up to the maximum amount of $750 per period.
  • You may submit the Request for Funds form with copies of receipts up to three times ONLY during the period until the $750 cap is met. All requests are subject to the availability of funds at the time of submission. Therefore, if partial reimbursement is initially received this does not guarantee you will receive the rest of the $750 later. Any request submitted over the 3x max will not be reimbursed.
  • The sooner in the period you submit your reimbursement, the greater the chance of being reimbursed as funds may run out before the end of the period and you avoid missing the deadline.
  • Be sure you are using the current forms (current forms are below), if you submit old forms, you will be notified to resubmit before the period ends, which can result in missing the deadline.

PLEASE FOLLOW STEPS BELOW TO BE SURE YOU ARE SUBMITTING REQUEST CORRECTLY

Step 1 - Check ALS Eligible Expenses List to make sure receipt(s) you are submitting are ON THE LIST of eligible expenses (if they are not on the list, they are not eligible) AND be sure receipts are between the acceptable date ranges for current period (dates below).

Step 2 - Complete Request for Funds form (please complete entire form),
Answer impact questions, Read each statement and put a check mark where it is required before you Read and Sign responsibility statement.

Step 3 - Attach COPIES of Receipt(s) that have already been paid for- You can use Mileage log or Respite Care Provider log if needed as receipts. ALL RECEIPTS MUST INCLUDE CLEAR DESCRIPTION AND DATE.

Step 4 - Return by fax or email (must be in the form of a scanned document as an attachment. Please do not send pictures included in the body of email). You can also mail the Request for Funds form with copies of receipts (Info provided below). PLEASE DO NOT SEND IN ORIGINAL RECEIPTS – SEND COPIES ONLY and retain a copy of your paperwork. If you need extra forms, please download below. You can also request by email or phone from a Care Services staff member.
See dates below. Do not wait until the last minute, if there is an issue with your submission and is received on the in-house date, you will not qualify for reimbursement for that period.

Step 5 - Recieve check which can take up to 6 weeks. Checks are void after 90 days and cannot be re-issued. Please deposit when you receive. If you do not receive check after 6 weeks, please contact Claudia Beirne at claudia@alsnc.org or 919-390-0125.

>>IMPORTANT DATES TO REMEMBER- LATE REQUESTS WILL NOT BE ACCEPTED, NO EXCEPTIONS <<

Grant Periods

Request for Funds form
along with eligible receipts

Receipts must be
dated between

 

MUST be postmarked by:

MUST be received In-House by:

 

1st (Jan. 21 – July 20)

HARD DEADLINE: July 15

HARD DEADLINE: July 20

Jan. 21 and July 20

2nd (July 21 – Jan. 20)

HARD DEADLINE: Jan. 15

HARD DEADLINE: Jan. 20

July 21 and Jan. 20



You can dowload Request for Funds Packet and extra forms below:

Download Current Request for Funds Packet  This includes procedure and all forms below

Download Current ALS Eligible Expenses List  Please be sure to check this form to make sure expenses qualify for reimbursement

Download Current Request for Funds Form This form MUST be completed, attached to an invoice/receipt and submitted for any reimbursements to be processed.
NEW - Fillable Request for Funds Form which can be completed and saved as a PDF and then emailed  

Download Current Respite Care Provider Log This form is used by non-professional (cannot reside in pALS’ home) respite care providers. It must be completed by the care provider and sent in with Request for Funds form.

Download Current Mileage Log  This form is used to submit reimbursements for Mileage OR rental of vehicle/car service to and from ALS clinic appointments, North Carolina clinical trial appointments (when travel stipend not provided), Feeding tube, invasive ventilator and Baclofen pump procedures appointments ONLY.  No other appointments qualify.