Safety Net

Application Requirements

1. Application is complete and signed by both the patient’s guardian and the Recommending healthcare provider.

2. In the case of attached receipts and support documentation, we should receive the following:

•  Transportation: Attach a description of required travel for treatment including treatment dates, to/from destination and either gas receipts for respective dates or mileage amounts for each specific reimbursement date being requested. If mileage is requested, we will reimburse at the approved IRS rate for medical mileage. We will either reimburse for mileage or gas receipts but not a combination of the two.
•  Medical Supplies: Include description of supplies or equipment being requested and corresponding receipt evidencing payment of equipment.
•  Medication: Include corresponding receipts for prescribed medication or over the counter medication needed. We will reimburse any out of pocket costs not covered by insurance.
•  Insurance Co Payment and Deductibles: Attach receipts for payment of any co-payment and/ or deductibles either for doctor visits, hospital stays, or medical care incurred for patient.

3. All receipts should fall within the treatment dates shown in the application.

4. Household Income Information – Attach latest Income Tax return for said household.