Transplant Patient Expense Reimbursement Program (TPER)

Application Form

I, the undersigned, understand that in making application to Trillium Gift of Life Network (“TGLN”) for expense reimbursement, I am required to provide the following information:

SECTION A: Patient Information

Name: ______

Last FirstInitial

Paediatric Patients Only:

Name of parent/guardian: ______

Last FirstInitial

Relationship: ______

Gender: M  F Date of Birth: ______

mm dd yyyy

OHIP Number: ______Transplant Hospital: ______

Transplant Type:  Heart  Lung  Heart - Lung

Primary Address: ______

City: ______Province: ______Postal Code: ______

Primary Telephone #: ______

Do you prefer correspondence via email:  Yes No Email: ______

I understand that the personal information provided in this application will be used only for the purposes of establishing my eligibility for accommodation reimbursement from Trillium Gift of Life Network. I further understand that TGLN may compile statistical information to report on their accommodation reimbursement program or for demographic purposes; no identifying personal information will be used for such reporting purposes.

If you have concerns about how TGLN manages your personal information please see or call the Privacy Officer at 416-363-4001 or 1-800-263-2833.

______Date: ______

Signature of applicant or parent/guardian mm dd yyyy

Name: ______OHIP #: ______

SECTION B: Funding from Other Programs

Please disclose funding from other government programs, registered charities, or other programs/activities that has been received to directly cover or partially cover accommodation expenses related to relocation for transplantation purposes:

______

Program (specify):Date ReceivedAmount ($)

______

Program (specify): Date Received Amount ($)

______

Program (specify):Date ReceivedAmount ($)

______

Program (specify):Date ReceivedAmount ($)

______

Program (specify):Date ReceivedAmount ($)

Name: ______OHIP #: ______

SECTION C: Local Accommodation Expense Details

If at any time the details of your local accommodations change (address, rental costs, etc), you
are required to notify the TPER Administrator immediately at 416-619-2342 / 1-888-977-3563.

Address of Relocation:

Street Address: ______

Unit / Apt. #______City/Town: ______

Province: ______Postal Code: ______

Local / Cell Phone #: ______

Lease/Rental Details:

Landlord: Name: ______

Address: ______

______

Contact Name: ______Contact Phone #: ______

Term of Lease / Rental Agreement:

Please provide documentation in support of your temporary relocation lease/rental agreement.

Starting Date: ______

Ending Date: ______

Monthly Lease / Rental Cost: ______

Name: ______OHIP #: ______

Payment Schedule:

Please complete the following schedule as completely as you can. Further information for subsequent months for consideration of reimbursement can be sent to TGLN at a later date.

To Be Completed by the Applicant / For TPER Administrator Use
Month / Date of Month / Lease/Rental Cost / Proof of Payment* / Proof of Payment Provided / Qualified Reimbursement ($) / Cheque # Issued
1
2
3
4
5
6
7
8
9
10
11
12
TOTAL

*- Proof of payment may include but is not limited to: receipts, cancelled cheques, credit card statements, and bank statements.

Name: ______OHIP #: ______

SECTION D: Certification

I hereby certify that the information provided on this application and in any documents attached, and in further information subsequently provided, is correct, complete and fully discloses all relevant sources of funding, including government funding, registered charities, or other programs/activities meant for specific and direct use to cover accommodation costs associated with relocation for transplantation purposes.

I also agree to notify TGLN of any changes that may affect my eligibility or continuing eligibility for receipt of reimbursement through this program.

______

Print name of Applicant or Parent/Guardian

______

Signature of Applicant or Parent/Guardian mm dd yyyy