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Theresa Bray Knowles Gaps in Care Fund Request Form

Community Care Partnership of Maine Gaps in Care Fund Request Form

The CCPM Gaps in Care Fund was established to address gaps in care and improve care coordination across the ACO. The fund is designed to allow our member organizations to request medically-related gifts-in-kind (medical equipment not covered by insurance, transportation assistance, etc.) for patients experiencing financial hardship. The program is funded by Community Care Partnership of Maine and administered in collaboration with the organization's care managers, clinicians, social workers and administrators.

To submit a request for an item or service, please fill out the form below in a complete and detailed manner. Incomplete requests will not be fulfilled. If you have any questions about a patient's eligibility, please consult the Gaps in Framework Eligibility Guidelines or contact Danielle Brown, Executive Administrator at daniellebrown@ccpmaine.org. Please note that the fund is intended for one-time assistance per patient.

Please do not include any identifiable information when completing this form. Identifiable information includes a patient's name, mailing address, date of birth, etc. Requests containing this information will not be processed.
1.Eligibility Verification(Required.)
REQUESTER INFORMATION
2.Requester name:(Required.)
3.Email address(Required.)
4.Requester job title (care manager, social worker, etc.):(Required.)
5.Requester phone number:(Required.)
6.Requester member organization:(Required.)
7.Practice address:
We will use this as the delivery address. NOTE: We are unable to deliver items directly to the patient. Do not put PHI in this field.(Required.)
PATIENT INFORMATION
8.Patient diagnosis/diagnoses (include only what is pertinent to the request)(Required.)
9.Patient insurance status (check all that apply)(Required.)
10.Primary care provider (must be a PCP within your organization):(Required.)
REQUEST INFORMATION
Please provide a detailed description of the following: 
11.The circumstances surrounding the request (e.g. This patient needs an air conditioner but cannot afford one, as she is uninsured and lives on a fixed income. The excessive heat in her apartment during the summer exacerbates her COPD.)(Required.)
12.A description of the item/service (e.g. The item is an air conditioner that can be installed in a window in the patient's apartment.):(Required.)
13.Impact/consequence(s) of the patient going without this item or service (e.g. Without a way to lower the temperature in her apartment, the patient overheats during the summer months, which makes it very difficult to her to breathe and triggers her COPD symptoms.):(Required.)
14.I attest that the item or service requested advances one or more of the following clinical goals (check all that apply):(Required.)
15.Please select the category that best describes the nature of the request:(Required.)
16.For what duration of time do you anticipate the patient will use this item or service?(Required.)
17.Can the requested item be purchased on Amazon?(Required.)
18.Please link the item below (on Amazon if at all possible):(Required.)
19.What is the cost of the item? (Please note that if the item costs more than $500, your request will be subject to a second review process.)(Required.)
20.Assuming the request is approved, please briefly explain your intended process for distributing the item or service (i.e. Care manager will give item to patient during next scheduled appointment, patient will pick up item from the practice, etc.)(Required.)
21.The connection between the item/service and the medical care of the patient (e.g. The air conditioner will help prevent exacerbation of COPD.):(Required.)
Current Progress,
0 of 21 answered