ALS Support Grants (ALS New Mexico)

ALS Support Grants (ALS New Mexico) is sponsored by ALS New Mexico. Through its grant program, ALS New Mexico provides financial assistance to help alleviate the costs associated with ALS care.

ALS New Mexico - Grant Application ALS United New Mexico (hereafter referred to as ALS NM) Quality of Life Care Grant Program provides funds for care for ALS NM members. We are making available grants of up to $2,500 per family per fiscal year to provide the family with some financial relief.

To be eligible, an individual must have a definitive diagnosis of ALS, PLS, or PMA, reside in the service area of New Mexico, and be registered with ALS NM.

ALS NM employees, board members and individuals holding positions of influence in the organization are eligible to apply for reimbursement for care services; however, they must recuse themselves from discussions and decisions about the program,its funding and individual award selections. Grants will be awarded based on the family's financial need and availability of funds.

To participate in the program, individuals must complete an enrollment form, review the policies and procedures for,m and return both to the chapter. Applications are reviewed and evaluated by the Patient Care Committee for eligibility and selection criteria. After assuring all the criteria are met, the Patient Service Committee will approve the grant, and then the Care Service Coordinator will contact the family.

*If the services were provided while the person living with ALS, PLS or PMA was alive, receipts submitted within 45 days of their passing, can be eligible for reimbursement. The grant year extends through each Fiscal Year (Feb 1-Jan 31). PLEASE NOTE: Eligibility can be determined by contacting your Care Coordinator.

Care Service Staff may request new signature page for any application that is ~90 days old, this is to ensure compliance with reporting requirements. Please be sure to check this list before submitting your reimbursement request or discuss with Care Service Coordinator. Note: You must attach a copy (no photos) of actual invoices, receipts, and/or proof of payment (copy of check) to this completed application to be submitted for review.

Respite: To be reimbursed for respite care, you must attach a care provider log or a professional receipt to this completed reimbursement form. If the care provider is not a professional, he or she must complete a “Log,” along with a copy of proof of residence, and attach to this completed Form.

*Log is on back page • Family or other non-professional caregiver not residing at the same address as the person living with ALS • Private Paid Caregiver-patients can be reimbursed directly for respite assistance by submitting an invoice marked paid which includes the patient’s name, address, dates of service, hours of care and the amount due.

The paid caregiver must be at least 18 years old, and must not be within the pALS immediate family. • Home Care Agencies- if a patient receives respite through a home care agency, the patient/family may pay the agency directly and request reimbursement from the Chapter, or, the home care agency may bill the Chapter directly after contacting the Care Services Coordinator for approval.

Invoices must state the patient’s name, address, dates of service, hours of care and the amount due. Communication: To be reimbursed for communication expenses, you must submit a copy of actual invoices or receipts and attach them to this completed Form.

• Tablet (limit 1 per person) and communication apps • Copays for speech generating devices • Headmouse and computer set up • Electronic writing tablets (example: Boogie Board) Medical Expenses: To be reimbursed for medical expenses, you must attach a copy of actual invoices or receipts to this completed Form.

• Prescription Copays: Rilutek/Riluzole, Radicava, Relyvrio and Nudexta ONLY • Copays for respiratory procedures and respirator devices; Feeding tube procedures, and feeding formula • Oral nutritional formula (example: Boost/Ensure); liquid thickener • Durable medical equipment: wheelchairs, wheelchair repairs, wheelchair batteries, lift chairs, Hoyer lifts & slings, shower/bath chair, rollator, bedside commode, etc • Orthotic Devices: AFO braces, hand splints, cervical collar, etc • Massage therapy provided by a licensed massage therapist (LMBT) • Personal emergency response system – installation • Counseling (individual and/or family) by a licensed provider Home Modifications: To be reimbursed for home modifications, you must attach a copy of actual invoices and receipts to this completed Form.

** • Materials and labor for home accessibility: grab bars, accessible toilet/seat riser, bidet, shower or bath modification, door widening, expandable door hinges, door knobs, walkways/driveways • Generator (limit 1 per person/only if ventilator dependent) • Portable or permanent ramps, platform lifts Transportation: To be reimbursed for travel/lodging for clinic, please provide “proof” of appointment such as discharge paperwork, electronic notification, or contact at clinic to verify (Note: We CANNOT accept gas receipts ) • Rental of vehicle or car service to and from ALS clinic appointments, feeding tube and/or vent procedures • Lodging for clinic appointment ONLY; 1 room/1 night limit, does NOT include meals • Automobile accessibility modification: wheelchair lifts, ramps, locking wheelchair mechanism Other: If you need to submit a reciept for an expense that is not covered above, please also submit no more than a 1-page explanation on how ALS NM support will benefit the family and how it is related to Grants will be reviewed by ALS NM and the Patient Services Committee and awarded as funds are available.

Please complete this enrollment form. Once completed, our Care Service Team will contact you with next steps. Please enter a valid phone number.

Format: (000) 000-0000. Payee Info - If different from person living with ALS Relationship to Applicant 2 digit month, 2 digit day, 4 digit year Date Home Care Company you are using (if known) Please enter a valid phone number. Format: (000) 000-0000.

Please enter a valid phone number. Format: (000) 000-0000. Signature of Applicant or Family Member * Browse Files Drag and drop files here