65 Willowbrook Boulevard – 2nd Floor
Wayne, New Jersey 07470
(973) 256-8484 VOICE / TTY
(973) 256-1233 FAX
Dear Applicant:
Thank you for your interest in The Special Needs Fund of Helpful Hands: The Northeast Regional Early Intervention Collaborative, Inc. A Committee of volunteers meets regularly to review applications and determine financial assistance awards. So please complete the application and return it as soon as possible.
The Special Needs Fund is supported solely by private donations and is subject to the success of Fundraising activities. Due to the limited availability of funds, assistance may not exceed $500 a year.
Although a family may re-submit an application after having previously received an award, priority consideration is given to first time applicants.
If you have any questions, please do not hesitate to contact me at 973-256-8484.
Thank you.
Sincerely,
Patricia L. Ciccone
Executive Director
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Page 2 of 9
THE SPECIAL NEEDS FUND OF HELPFUL HANDS:
THE NORTHEAST REGIONAL EARLY INTERVENTION COLLABORATIVE, INC.
Purpose: To provide assistance to families of infants and toddlers with disabilities under age 3 impacted by the high costs of supports/services not covered through Part C, medical insurance, MEDICAID and/or other private or public funding sources.
Eligibility Criteria:
1. Applicant must be resident of and receive Part C early intervention services in Bergen, Hudson or Passaic Counties, New Jersey.
2. Applicant must be the primary legal care giver(s) for the infant or toddler.
3. Applicant must have a signed Individualized Family Service Plan (IFSP) in which the requested service (s) or device (s) are:
A. Related to the stated outcomes.
B. Identified on the IFSP Service Pages.
4. Applicant must complete and sign the full application and submit it with the following attachments.
A. Dated copies of bills, invoices or receipts along with statement (s) of partial payment/rejection of benefits from insurance, MEDICAID, and/or other public or private funding sources.
B. A letter written by the parent/caretaker stating why they are requesting assistance from the Special Needs Fund.
C. A letter of support from the child’s Special Child Health Services Case Management Unit Service Coordinator. (An additional letter of support from the Early Intervention Provider may also be submitted).
D. A copy of the current IFSP.
Eligible Services and Equipment:
1. Community Activities/Programs as identified in IFSP.
Example: Membership, tuition or other support, which helps child participate in community activities with children who do not have disabilities. Community activities could include, YMCA swimming lessons, Gymboree, story-time at the library, etc.
Services and Equipment NOT Eligible for Assistance by the Special Needs Fund: Medical Services (diagnostic evaluations); Clothing, unless adaptive in nature; Insurance co-payments; Diapers; Formula and nutritional supplements; Services/Supports not listed on the IFSP service pages.
2. Adaptive/Assistive Devices/Orthopedic Equipment:
For example: Any item, piece of equipment, or toy that is used to increase, maintain, or improve the functional capabilities of children with disabilities.
Special Requirements for Devices or Equipment
A. A statement of need signed by a physician or medical professional must be attached to application. (Except for adapted toys)
B. If the funds requested will only partially support the purchase of the device or equipment, an explanation of how the remaining balance will be paid (such as, time payments, personal loan, other foundations, a community fundraising, etc.)
3. Respite/Child Care Services
Definition: Child care or respite services to help meet the needs of the family and primary care providers.
4. Conferences
Definition: Conference or Workshop registration related to child’s special needs.
Time Lines for Submission of Awards of Assistance:
1. Expenses submitted may not be more than 1 year old as of the date of submission of the application.
2. Applications should be mailed to:
The Special Needs Fund
HELPFUL HANDS - NREIC
65 Willowbrook Blvd., 2nd Floor
Wayne, New Jersey 07470
Decision Process for Assistance:
Decisions on the provision of assistance will be made by a volunteer committee appointed by the Executive Board of the NREIC. The committee will include a parent of a child who receives or previously received Part C Early Intervention Services, a representative of the Executive Committee of the Board of Trustees, and an Early Intervention Professional who is familiar with the needs of infants and toddlers with disabilities and their families.
Assistance will not exceed FIVE HUNDRED DOLLAR ($500) per year and will be limited by the availability of financial resources within the NREIC Special Needs Assistance Fund.
THE SPECIAL NEEDS ASSISTANCE FUND IS SUPPORTED SOLELY BY PRIVATE DONATIONS AND IS NOT PART OF NEW JERSEY’S STATE-FUNDED EARLY INTERVENTION PROGRAM.
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Page 3 of 9
OF HELPFUL HANDS: THE NORTHEAST REGIONAL EARLY INTERVENTION COLLABORATIVE, INC.
PLEASE PRINT:
Child’s Name: ________________________________ Date of Birth: _______________
Date of Most Recent IFSP: ___________ Name of Service Coordinator: _____________
Have you previously submitted an application? ___No ___Yes if yes, Date: __________
Name (s): _______________________ Name (s): ________________________
Address: ________________________ Address: _________________________
City: _____________ Zip: _________ City: _____________ Zip: __________
County: _____________ County: _____________
How long resident of New Jersey? ____ How long resident of New Jersey? ____
Phone: (home)_____________ Phone: (home) _____________
(work) _____________ (work) _____________
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Principal Place of Employment: Principal Place of Employment:
________________________________ _________________________________
Street Address of Employer: Street Address of Employer:
________________________________ _________________________________
City, State, Zip: City, State, Zip:
________________________________ _________________________________
Occupation: Occupation:
________________________________ _________________________________
( ) Full-time ( ) Part-time ( ) Self-Empl. ( ) Full-time ( ) Part-time ( ) Self-Empl.
I have attached the following:
___A. Dated copies of bills, invoices or receipts along with statement (s) of partial payment/rejection of benefits from insurance, MEDICAID, and/or other public or private funding sources.
___B. A parent/caretaker letter requesting assistance.
___C. A letter of support from the child’s Special Child Health Services Case Management Unit Service Coordinator.
___D. Copy of Current IFSP.
___E. A statement of need signed by a physician or medical professional. (For Adaptive/Assistive Devices/Orthopedic Equipment only)
___F. A statement describing how the remaining balance bill will be paid (If exceeds the amount requested)
I certify that:
1) these expenses are related to the needs of my child as identified on his/her IFSP.
2) these expenses were not paid by any other source.
3) all the information contained in this application is true.
4) the financial assistance will be used for the approved purposes.
5) the final determination of eligibility will be made the NREIC.
_______________________ ______________
Signature of Applicant Date
Please forward payment directly to the following provider: ______________________
______________________
______________________
______________________
_______________________ ______________
Signature of Applicant Date
Child’s Name: __________________________ Date of Birth: ________________
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DATE
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DEVICE/EQUIPMENT |
COST |
INSURANCE/ MEDICAID |
OTHER FUNDING SOURCES |
DIFERENCES |
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TOTAL ADAPTIVE/ASSISTIVE DEVICES/ORTHOPEDIC EQUIPMENT $______________
RESPITE/CHILD CARE SUPPORT
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DATE
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RESPITE/CHILD CARE |
COST |
INSURANCE/ MEDICAID |
OTHER FUNDING SOURCES |
DIFFERENCES |
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RESPITE/CHILD CARE SUPPORT SERVICES TOTAL $ ______________
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COMMUNITY ACTIVITIES SUPPORT
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DATE
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COMMUNITY ACTIVITY |
COST |
INSURANCE/ MEDICAID |
OTHER FUNDING SOURCES |
DIFFERENCES |
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COMMUNITY ACTIVITIES SUPPORT TOTAL $ ________________
CONFERENCES
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DATE
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CONFERENCE |
COST |
INSURANCE/ MEDICAID |
OTHER FUNDING SOURCES |
DIFFERENCES |
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CONFERENCE REQUESTED $________________
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For office use only: Date: _____________ Initials: ________
$ ___________ Adaptive/Assistive Devices/Orthopedic Equipment
$ ___________ Respite/Child Care Support
$ ___________ Conferences
$ Community Supports
==========
$ Total Approved (not to exceed $500 year)
____________
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Page 7 of 9
In your own words, describe your need for the requested assistance:
STATEMENT OF SUPPORT FROM SPECIAL CHILD HEALTH SERVICES CASE MANAGEMENT UNIT SERVICE COORDINATOR
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Page 8 of 9
Referrals to Other Sources:
DATE OUTCOME
( ) SSI ___/___/___ ______________________________
( ) Medicaid ___/___/___ ______________________________
( ) Medically Needy ___/___/___ ______________________________
( ) Model Waiver ___/___/___ ______________________________
( ) Catastrophic Illness ___/___/___ ______________________________
( ) New Jersey Care Special
Medicaid Project ___/___/___ ______________________________
( ) Charity Care ___/___/___ ______________________________
( ) Community Services (list)___/___/___ ______________________________
( ) Other _____________ ___/___/___ ______________________________
Please provide a brief statement of need and clinical/social summary:
Date Application Received from Family: ___/___/___
Date mailed to NREIC office: ___/___/___
Signature of Case Manager: _______________
Phone: __________
County: __________
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Page 9 of 9
The Family seems to be the most
effective and economical system for fostering and sustaining the child’s
development.
Without family involvement, intervention is likely to be
unsuccessful, And what few effects are achieved are likely to disappear once the intervention is
discontinued. — Urie Bronfenbrenner
Copyright 2007