Please click on the links below to download program applications, forms and documents, and for access to various transplant-related links and resources.
- Academic Scholarship application (pdf)
- Dental Assistance application (pdf)
- Financial Assistance application (Spanish pdf)
- Evaluation Assistance Application (pdf)
- Financial Assistance Application (pdf) (this application is for the Emergency, Lodging, Insurance and Transportation Assistance Programs)
- JumpStart Enrollment Application (pdf)
- Living Donor Assistance Application (pdf)
- Pediatric Assistance Application (pdf)
- Transplant Fundraising Program application (pdf)
- Auction Donation Form (pdf)
- Become a Mentor (online form)
- Dental Fee Schedule (pdf)
- Dental Provider Agreement Form (pdf)
- Dental Provider Information (pdf)
- Donation Form (pdf)
- JumpStart Community Partner Evaluation Form (pdf)
- PR Release Form (pdf)
- Request a Mentor (online form)
- Tutoring Provider Agreement Form (pdf)
- Tutoring Provider Information Form (pdf)
- Volunteer Information Form (pdf)
- Piedmont Transplant Institute
- Emory Transplant Center
- Augusta University Medical Center
- Children's Healthcare of Atlanta
- National Kidney Foundation
- American Kidney Fund (AKF)
- American Association of Kidney Patients
- United Network for Organ Sharing (UNOS)
- Donate Life America
- Children’s Organ Transplant Association
Government Assistance Resources
TRANSPLANT FUNDRAISING PROGRAM-RELATED DOCUMENTS AND FAQ'S
- Once they have completed their evaluation, anyone being transplanted in a transplant center in the state of Georgia can apply for the Unmatched Funds Program.
- Matched Funds Program applicants must be residents of the state of Georgia for at least six months before application. This also holds true for Georgia residents who are being transplanted outside the state of Georgia.
- Fill out the application at https://gatransplant.org/our-programs/transplant-fundraising-program/ or receive one from your transplant center financial coordinator or via the USPS mail from GTF.
- Fill out the application completely.
- Return the completed application with ALL the necessary documentation:
- Proof of Residency: this can be a copy of your driver’s license (or non-driver’s ID) with the ISSUE date of six (6) months older than the application date (the issue date is located next to your date of birth), a six (6) month old utility bill, a six (6) month old bank statement, a letter from your dialysis or transplant center stating that you have been a patient there for six (6) months. This document should include your name, current address and a date six (6) months prior to the date you are completing the application.
- Proof of Income for EVERY ADULT (18 years or older) in the household. This can be in the form of your most recent pay check stub, a Social Security Income statement, a bank statement showing monthly Social Security check deposit, or the household’s most recent Federal Income Tax return.
- Proof of Insurance: a front and back copy of your Medicare, Medicaid, and/or private insurance card. If you do not have health insurance, please note that on the application.
The application and enrollment process can take up to thirty (30) business days and must be completed before you have your transplant in order for you to be eligible for the Matched Funds Program. The application process will take longer if:
- The application is not complete upon submission.
- You do not include all the needed documentation with the application upon submission.
- You have not completed you evaluation before you submit the application.
- You do not return your client agreement, signed and completely filled out in a timely manner.
- The Matched account is primarily for clients with great financial need, applying before transplant whose financial needs concentrate on having the funds available for their post-operative medications. It provides a dollar for dollar match up to $10,000 if raised in the first year.
- You can only access $1,000 for non-prescription medication reimbursement if you are in the matched funds program.
- The Unmatched account is primarily for clients who have a lesser financial need or who are applying post-transplant, or for those clients whose greatest financial need is for cost arising from travel or medical bills and insurance premiums. The funds can be used for post-operative medications or for other post-operative needs that meet the GTF guidelines such as lodging and travel after the transplant.
- Clients may utilize the blue envelopes they receive in their Welcome packets to send in contributions they received from their fundraising efforts.
- All donations received in blue envelopes are considered by GTF to have been already acknowledged by the client, and the donator doesn’t receive acknowledgement from GTF.
- Donors may send their gifts directly to GTF.
- Gifts received directly from donors will be acknowledged to both the donor and the client.
- Donations may be made via the client’s TFP website.
- Each client who has had activity on their account, deposits or payments, is eligible to receive a quarterly statement. You may call or email the TFP Program Manager to request your statement. Requests for statements may be made every ninety (90) days.
- Should you need your balance in between statements, call or email the TFP Program Manager to request the balance. The email must come from the email address associated with your TFP account. Requests for balances may be made every thirty (30) days.
To submit expenses for reimbursement, fill out the required form completely. Include:
- Store receipts or mail invoices for all prescription medications.
- Proof of Payment for all medication expenses
- Proof of the Appointment and Proof of Payment for each travel expense - Remember you are to pay up front and have the costs reimbursed with funds from your account.
- Total all expenses and sign and submit the form.
All Reimbursements are processed on a monthly basis, on the 15th. The forms and all supporting documentation must be received at GTF’s TFP offices before the 15th of the month. Any forms received after the 15th will be processed with the next month’s requests.
All TFP accounts are subject to a 3% administrative fee.
- The fee is assessed from each deposit into the client’s account.
- In the life of the account, if you deposit $10,000 the administrative fee is only $300.
- All donations made via the websites are assessed an additional 2.85% credit card processing fee.
If you are taken off the list for any reason or move to another state, your TFP matched account will be transferred to an unmatched account and you will then be able to immediately start to utilize the funds via the reimbursement process and it can be used for prescriptions and any medical bills that would have fallen under the $1,000 cap in the matched program.