Patient Assistance Grants

KCNQ2 CURE PATIENT ASSISTANCE GRANT

The KCA Patient Assistance Grant program provides financial support for necessary medical equipment, therapy devices, and educational tools for individuals with KCNQ2-related encephalopathy not covered by private insurance or other programs. It is accessible globally to anyone with a confirmed diagnosis of a KCNQ2-related encephalopathy variant. The application period begins annually on March 2nd on International KCNQ2 Awareness Day and ends on December 1st or when funding is exhausted.

Applications are processed on a first-come, first-served basis. Each applicant is eligible to apply once per funding period, with a cap of $1,500 annually and a lifetime limit of $5,000.

KCA PATIENT ASSISTANCE GRANTS – QUALIFYING ITEMS

Durable medical goods (such as wheelchairs, orthotics, cooling vests, etc.)
Therapy equipment
Therapies not covered by insurance (such as therapeutic horseback riding, aquatic therapy, etc)
Communication devices, such as iPads

The program does not cover medical or pharmaceutical co-pays, respite assistance, or service animals.

If you are applying for an iPad, please note  the PAG program only covers either an iPad (128GB, Wi-Fi only) or an iPad mini (256GB, Wi-Fi only). If you were granted funding for an iPad previously, there is a 3-year minimum before you may reapply for a new one. We do not provide AppleCare insurance, but you may add it later at your own cost. We highly suggest you purchase a durable cover or add it to your application to help protect the device.

If the equipment you are interested in is not listed above or you are requesting more than 3 items, please contact us with more details on the requested item, and we can review its eligibility.

APPLICATION REQUIREMENTS

Your application should contain:

A filled-out application form
A recent letter from a physician or healthcare provider detailing the medical need for your request
A recent letter from a neurologist or geneticist confirming the diagnosis of KCNQ2-related encephalopathy
If applicable, a denial letter from your insurance company for the requested items or services
Any other relevant documents related to your request. Privacy of all submitted information is assured.

Incomplete applications, or those lacking required additional information, will be put on hold until completed. Applications not completed within 60 days will be considered expired. All applicants will be notified via email regarding the outcome of their application. Those who are denied can reapply if they provide new documentation showing a change in their situation or the ineffectiveness of other alternatives. The review process for applications can take up to 45 days.

Questions or need help? Email info@kcnq2cure.org

Application for Caregivers

Name(Required)

First Last

Have you previously applied for a grant from the KCNQ2 Cure Alliance?(Required)

Yes

Unsure

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Patient Name(Required)

Date

Gender(Required)

Male

Female

Child's Diagnosis(Required)

(include primary and secondary, if applicable)

Equipment Requested(Required)

(Provide exact name of equipment/service; name of manufacturer or provider; and the name and contact information for the vendor. If available, please attach brochure and/or photos. If you are requesting more than 3 items, please contact KCA prior to submission.)

Estimated Cost(Required)

Please research the cost of your item(s) before submitting your application. An estimated cost must be entered, or your application will be rejected.

Physician Letter(Required)

Max. file size: 50 MB.

Proof of Diagnosis(Required)

Max. file size: 50 MB.

Insurance Denial Letter

Max. file size: 50 MB.

Other Documentation

Max. file size: 50 MB.

Disclosure of Health Information(Required)

I acknowledge

The applicant confirms that they intend for KCNQ2 Cure Alliance (KCA) to be treated as they would be with respect to their rights regarding the use and disclosure of individually identifiable health information or other medical records. It is the applicant’s intention to waive the requirement that KCA be given only the "minimum necessary" information, and it is the express intent that KCA shall have full and unfettered access to any and all information that the applicant provides personally or via any other personal representative. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1320d and 45 CFR 160-164. This Authorization to Disclose Health Information is intended to be a "valid authorization", as that term is used in the Health Insurance Portability and Accountability Act of 1996, as amended, and in regulations promulgated thereunder, including, without limitation, 45 C.F.R. §164.508, or any successor regulatory provision. This authorization shall terminate on the first to occur of: (1) One (1) year after application to the KCA Patient Assistance Program; or (2) Upon my written revocation actually received by the KCA. Proof of receipt of my written revocation may be by certified mail, registered mail, facsimile, or any other receipt evidencing actual receipt by the covered entity. This revocation shall be effective upon the actual receipt of the notice by the covered entity except to the extent that KCA has taken action in reliance on this Authorization. By checking this box for Authorization, the applicant acknowledges that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the person or persons named in this authorization, and the information, once disclosed, will no longer be protected by the rules created in HIPAA. The applicant understands that although federal law does not protect health information disclosed to someone other than another health care provider, health plan, or health care clearinghouse, under Colorado law, all recipients of health care information are prohibited from re-disclosing such information except as specifically required or permitted by law. The applicant understands they have the right to receive a copy of this authorization upon request.

Signature(Required)

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Patient Assistance Grants

KCNQ2 CURE PATIENT ASSISTANCE GRANT

KCA PATIENT ASSISTANCE GRANTS – QUALIFYING ITEMS

APPLICATION REQUIREMENTS

Application for Caregivers

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Patient Assistance Grants

KCNQ2 CURE PATIENT ASSISTANCE GRANT

KCA PATIENT ASSISTANCE GRANTS – QUALIFYING ITEMS

APPLICATION REQUIREMENTS

Application for Caregivers

Contact Us

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