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9th NLN International Conference 9.22.2010

Conference Registration Now Open

NLN Position Papers: Risk Reduction, Treatment, Exercise, Air Travel, Training

Financial Assistance for Garments:

New Books:
100 Questions and Answers About Lymphedema

Lymphedema Management: A Comprehensive Guide for Practitioners

Updated NLN Online Patient Questionnaire

Patient participation in clinical trial

For Professionals: NLN Research Survey

Review Process

Only complete applications will be reviewed, please be sure to include all the requested documents and answer all the questions in the Medical History section. You can email the application and requested documents or send it via regular mail, no faxes please.

All applications will be reviewed by a committee consisting of lymphedema therapists, lymphedema product company representatives and the NLN; all of your personal information will be kept confidential within the review committee. Please allow 2 - 4 weeks for review. You will be notified by mail of the decision. Please note: patients who are awarded garments will only receive one set of garment(s) per calendar year.

Requirements

- Patient must be a member of the National Lymphedema Network (for more information on membership, click here)

- Patient must be receiving treatment at an NLN affiliated clinic or with an NLN affiliated therapist. Please contact the NLN office for a list of affiliated clinics and therapists. (or click here to search by zipcode)

- Patient must demonstrate genuine financial need

- Patient must complete the brief Medical History

- Patient must provide the completed form from your current lymphedema therapist or physician stating the diagnosis, severity of the lymphedema and reason why the garment is medically necessary. (click HERE to download, then print)

- Patient must provide a brief (1 – 2 pages) biographical sketch detailing why he/she should be considered for the fund

- A copy of the prescription for the garments. Make sure this includes the name of the company, style of compression class.

- Patient must submit a $25 non-refundable application fee, by check or credit card.

 

Materials and questions can be emailed to nlngarmentfund@lymphnet.org.

PAPER APPLICATION

To apply through the mail, print and complete the following form: (click here)

ONLINE APPLICATION

To apply online (recommended) fill out the following form and click the "Submit" button at the bottom of this page.

1. Applicant Information

* Nln member number
First Name:
Last Name:
Mailing Address:
City:
State:
* Zip/postal code
Outside the usa?
Foreign State:
Foreign Country
Daytime Phone: Ext.
Facsimile Number:
Email Address:
Gender:
Name of Guardian
(if patient is a minor)

* Please make sure that your Zip/Postal code and your NLN Member Number are accurate and current.

By clicking here you acknowledge the release of your information (Personal information submitted will be stored confidentially and used only for purposes of application review and program evaluation.)

2. Financial Need

annual household income:
(us dollars)
number of family members supported by this income:
IS the annual household income provided solely by one individual, or is this a joint salary range?

income sources

(please check all that apply and include details in your biographical sketch, below)

Social Security (retirement)
Alimony
Salary
Pension
Public Assistance
Short Term Disability
In-Kind (room and board)
Child Support
Family/Friends provide support
SSD (Disability)
Unemployment
SSI
Sick Leave Pay
are you self-employed?
For how long?
Type of business?
are you currently employed?
Name of your employer/institution:
Title/Position:
For how long?

other income?

(please specify)

3. Health Insurance

do you have health insurance?

What percentage of your garment costs does your insurance cover?
How much is your DME deductible? (US Dollars)
Have you met your DME deductible yet this year?
How much is your co-pay?
(US Dollars)
What type of Health Insurance?
other insurance?
(please specify)

4. Brief Medical History

Year of birth
type of lymphedema
Secondary LE caused by:
Type of Cancer:
Year of surgery:
How long after your surgery did the LE present?
are you under the care of a certified lymphedema therapist/clinic?

(if yes, check the box and provide details below)
Therapist's Name:
Name of Clinic :
(if applicable)
Therapist's Address:
Therapist's Phone:
Therapist's Email
affected areas (select all that apply)
Arms:
Legs:
Other areas:
are you currently wearing a compression or alternative garment?
Garment Company:
Garment Cost:
(in US Dollars)
Garment Type:
 Upper Garment Type:
 Lower Garment Type:

for assistance in describing the style, please choose the image that most closely represents the garment you currently wear.

(make sure you have filled in the 'affected areas' above, and clicked the checkbox just below them)


4. Other Information

who prescribes your garment(s), your therapist or physician?
how many garments do you use per year?
who orders the garments, you or your therapist?
if you have insurance, what is their reason for denying payment of the garments?
who bills the insurance, you or your therapist?
How would you describe the severity of your condition? I am disabled due to lymphedema (formal disability, ie SSI, employer disability, has been made).
Lymphedema is severe and impacts my ability to carry out daily tasks.
Lymphedema control will not be optimal unless new compression garment is worn.
anything additional you would like to add:

brief biographical sketch:

(NOTE: This is a required section of the application!)

5. Payment Information

I will pay the $25 application fee by: Check
Charge Card Number:
Expiration Date: (00/00)
My Name:
(acts as your signature)
Note:

6. Submitting

Before submitting, please carefully check your information for accuracy.

NOTE: See the next page for additional materials which must be submitted!

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