Care Grant Program
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, home modifications, handicap 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.
- This is a reimbursement grant program which will reimburse up to a maximum amount of $750 per period.
- 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
- Confirm receipts are between the acceptable date range of 12 months prior to submission.
Step 2 - Complete Request for Funds Form - Both sides must be fully completed
Step 3 - Attach COPIES of Receipt(s) – 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.
- You can use Mileage log or Respite Care Provider log if needed as receipts
Step 4 - Return by fax or email (must be in the form of a scanned document as an attachment (PDF). Please do not send pictures included in the body of email).
You may also mail the Request for Funds form with copies of receipts (address provided on pg. 4). PLEASE DO NOT SEND IN ORIGINAL RECEIPTS. Retain a copy of your paperwork for your records. If you need extra forms, Please download the forms you need on this page. You can also request by email or phone from a Care Services staff member.
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 6 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 6 weeks, please contact Claudia Beirne at firstname.lastname@example.org or 919-390-0125..
Download Current Request For Funds PACKET This includes procedure and all forms below
Download Current ALS Eligible Expenses ONLY Please be sure to check this form to make sure expenses qualify for reimbursement
Download Current Request For Funds Only This form MUST be completed, attached to an invoice/receipt and submitted for any reimbursements to be processed.
Request For Funds Fillable which can be completed and saved as a PDF and then emailed
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.