Care Grant Program

YOU CAN NOW COMPLETE "REQUEST FOR FUNDS" FORM DIRECTLY ONLINE  (Scroll down to complete form}
PLEASE READ ALL INSTRUCTIONS FIRST

The ALS United North Carolina Care 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, handicap accesible home modifications, handicap accessible 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 YOU MUST HAVE A VERIFIED DIAGNOSIS OF ALS or PLS. ALSU NC has the right to request updated ALS Verification if person with ALS has not attended an ALS Clinic for 2 or more years.

 IMPORTANT INFORMATION

  • This is a reimbursement grant program which will reimburse up to a maximum amount of $750 per period (2 periods/year).
  • In order to receive funds, you must follow the” Instructions for Applying” below.
  • 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 you being reimbursed, as funds may run out before the end of the period.

INSTRUCTION FOR APPLYING (please follow steps below to be sure you are submitting request correctly)

Step 1 – Ensure expenses qualify for reimbursement. Verify that receipts are for items on the ALS Eligible Expenses List AND receipts are between the acceptable date range of 12 months prior to submission.

Receipts must be for items that are already paid for and MUST INCLUDE CLEAR DESCRIPTION AND DATE. Please note, for medical appointments, please be sure the receipt has a description of the appointment and date of appointment/payment or it will not be eligible for reimbursement.

  • You can use Mileage log (for ALS related transportation) or Respite Care Provider log (for non-professional respite care provider) if needed as receipts
  • If you are submitting "AMAZON" or other online store receipts, please submit copy of the "order details" page, NOT image/photo of each item or part of receipt.

Step 2 - Complete online Request for Funds form below, if you are not able to complete online, you may also download forms (on this page) and email or fax .

Step 3 - Attach COPIES of Receipt(s) – All receipts need to be in PDF format attachments. If you are submitting for Respite Care (non-professional only) or Mileage you will need to download forms on this page, complete, then scan and upload same as other receipts. for respite care, please remember to upload copy of ID of care provider.

Do not wait until the last minute to submit your reimbursement, if there is an issue with your submission there may not be adequate time to process your request.

Step 5 - Receive check, which can take up to 8 weeks.  Checks are void after 90 days and cannot be re-issued.  Please deposit when you receive. If you do not receive a check AFTER 8 weeks, please contact Claudia Beirne at claudia@alsnc.org or 919-390-0125.

Grant Deadline Image

Request for Funds Form

Once you complete form, it will be submitted and you will receive a confirmation email. (please keep this for your records). If you have any questions, please contact Claudia Beirne at claudia@alsnc.org or 919-390-0125.

ALS United North Carolina Care Grant - Request for Funds Form

Complete this form to submit a Request for Funds and upload your receipts (at the bottom of the page) that match the amount you are requesting. Receipts must be clear and MUST include a description of service/purchase and all other information required according to the Instructions for Applying on the main Care Grant page. You may submit Request for Funds with eligible receipts up to 3 times/period, for a maximum of $750.

Person with ALS(Required)
Mailing Address(Required)
If mailing address is a PO Box, you must provide a physical address below
Physical Address (must provide if the above address is a PO BOX) Or different from mailing address
Product/Service Requesting for Reimbursement(Required)
Please add the reimbursement amount under each category that applies, up to a total of $750 (or remaining balance of your grant).
Clinic Currently Attending(Required)

Primary Caregiver Information(Required)
Address(Required)
All receipts must be clear and have a date, amount paid, place of purchase information (company name, address, phone number) and a CLEAR DESCRIPTION of item/service and on the ALS Eligible Expenses List. Receipts need to be uploaded in PDF format.
Drop files here or
Accepted file types: pdf, Max. file size: 10 MB.
    STOP: Before Submitting, Please make sure the following is Accurate(Required)
    By submitting this Care Grant Request for Funds and signing below, I assume personal responsibility for understanding the ALS United North Carolina Care Grant Request for Funds process, eligible expenses, and hard deadlines. If ANY OF THE ABOVE IS NOT ACCURATE, I understand that I will not receive reimbursement for these items. I also understand that no exceptions will be made to the grant deadlines and all grants are subject to availability of funds. If false information is provided, I understand that ALS United NC has the right to refuse reimbursement of funds and also if I submit the same receipts more than once, I will be no longer eligible for the ALS United North Carolina Care Grant.(Required)
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    Grant forms for downloading 

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

    Download Current Respite Care Provider Log Only 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 and a copy of care provider ID.

    Download Current  Mileage Log ONLY 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 procedures, invasive ventilator procedures, Baclofen pump procedures and Radicava Treatments appointments ONLY.  No other appointments qualify.

    Download Current Request For Funds Only This form MUST be completed, attached to invoice(s)/receipt(s) and submitted for any reimbursements to be processed.