Payment to Family (Form)

Payment to Family

Complete this form to apply for a grant to allocate funds for transplant-related expenses.

1Patient Info

2Medical Expenses

3Travel Expenses

4Other Expenses

5Payment Info

Please refer to our Family Services Guide for details of the documentation required for each type of expense and payment.
Expense Description*

Please enter a brief description of these expenses.
Hidden
Status
Hidden
Status Description

This text will appear within the tooltip on the front-end.
Enter COTA Patient Name*
First Last
What is the patient's current transplant status?*
Hospital Name*
City, State for Transplant Appointment/Hospitalization Expenses*
Number of Caregivers during Transplant Appointments/Hospitalizations*

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Transplant-Related Medical Expenses
Do you have transplant-related MEDICAL expenses to submit?*
(Examples: transplant-related medications, transplant co-pays, transplant over-the-counter medications/supplies, transplant counseling)
- Yes
- No
Medical Expense(s) Selection
- RX Co-Pay(s)
- Provider Co-Pay(s)
- Over the Counter Medication(s)
- Other Medical Expense(s) – Please Describe
Please check a box for each type of transplant-related medical expense you wish to submit.
RX Co-Pay(s)*
Enter total $ amount for all RX Co-Pay(s).
Date of Expense(s)*
MM slash DD slash YYYY
Add attachment for each expense claimed.*
Drop files here or

Max. file size: 256 MB.
Provider Co-Pay(s)*
Enter total $ amount for all Provider Co-Pay(s) to be submitted.
Date of Expense(s)*
MM slash DD slash YYYY
Add attachment for each expense claimed. (5 max)*
Drop files here or

Max. file size: 256 MB, Max. files: 5.
Over The Counter Medication(s)*
Enter total $ amount for all OTC Medication(s).
Date of Expense(s)*
MM slash DD slash YYYY
Add attachment for each expense claimed. (5 max)*
Drop files here or

Max. file size: 256 MB, Max. files: 5.
Please describe other expense(s)
Other Medical Expense Amount*
Enter total $ amount for all Other Medical Expense(s).
Beginning Date of Expense(s)*
MM slash DD slash YYYY
Ending Date of Expense(s)*
MM slash DD slash YYYY
Add attachment for each expense claimed. (5 max)*
Drop files here or

Max. file size: 256 MB, Max. files: 5.
Total Medical Expenses Submitted

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Transplant-Related Travel Expenses
Do you have transplant-related travel expenses to submit?*
(Food, Transportation, Lodging, etc.)
- Yes
- No
Please attach documentation of each transplant-related appointment or hospitalization that you plan to include an expense for below.*
Each expense claimed below will need to reflect a date or date range that corresponds to the date of this transplant-related appointment or hospitalization in order to be approved.
Drop files here or

Max. file size: 256 MB, Max. files: 5.
Travel Expenses
- Food
- Transportation
- Lodging
- Other – Please Describe
- Mileage
Choose all that apply
Dollar amount for Food*
Beginning Date of Expense(s)*
MM slash DD slash YYYY
Ending Date of Expense(s)*
MM slash DD slash YYYY
Add attachment for each Food expense claimed. (5 max)*
Drop files here or

Max. file size: 256 MB, Max. files: 5.
Dollar amount for Transportation Expenses.*
Beginning Date of Expense(s)*
MM slash DD slash YYYY
Ending Date of Expense(s)*
MM slash DD slash YYYY
Add attachment for each expense claimed for Transportation Expenses. (5 max)*
Drop files here or

Max. file size: 256 MB, Max. files: 5.
Dollar amount for Lodging Expenses*
Beginning Date of Expense(s)*
MM slash DD slash YYYY
Ending Date of Expense(s)*
MM slash DD slash YYYY
Add attachment for each expense claimed for Lodging Expenses. (5 max)*
Please attach a receipt for each expense claimed in this category.
Drop files here or

Max. file size: 256 MB, Max. files: 5.
Please describe other expense(s)*
Dollar amount for Other Expenses claimed.*
Beginning Date of Expense(s)*
MM slash DD slash YYYY
Ending Date of Expense(s)*
MM slash DD slash YYYY
Add attachment for each expense claimed for Other Expense(s). (5 max)*
Drop files here or

Max. file size: 256 MB, Max. files: 5.
Mileage*
Enter Number of Miles Driven for Transplant-Related Trips
Beginning Date of Expense(s)*
MM slash DD slash YYYY
Ending Date of Expense(s)*
MM slash DD slash YYYY
Mileage Cost Calculator
Calculated at 22 cents per mile.
Total Travel Expenses Submitted.

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Payment Options
Total Expenses To Be Processed
How would you like to receive grant funds?
You will have the opportunity to setup direct deposit in this form if this option is chosen and you have not yet set up this service.
Have you already setup direct deposit with COTA?*
- Yes
- No
Direct Deposit Agreement Section
Please complete this section to setup your account for direct deposit of funds. Please note, funding may be delayed until verification of direct deposit setup is complete.
Primary Account Holder's Name*
First Last
Name of Financial Institution*
Account Type
Routing Number*
Account Number*
Please include all numbers exactly as printed, including any beginning with zero’s.
Please attach an image of a voided check for the listed account*
Drop files here or

Max. file size: 256 MB, Max. files: 5.
Direct Deposit Authorization Agreement*
- I Agree to these terms and conditions
I hereby authorize the Children’s Organ Transplant Association to initiate automatic deposits to my account at the financial institutions named in this section. I also authorize the Children’s Organ Transplant Association to initiate withdraws from this account in the event that a credit entry is made in error. Further, I agree not to hold the Children’s Organ Transplant Association responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account. This agreement will remain in effect until the Children’s Organ Transplant Association receives written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Children’s Organ Transplant Association.
Enter the account holder's name currently set up with direct deposit.*
First Last
Thank you for confirming you have already setup direct deposit with COTA.
Please complete the remaining sections below and submit this form. Funds will be direct deposited into the direct deposit account you have set up for COTA to use once approved.
Make Check Payable to:*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
- Check this box if this is a new address
Grant Application Agreement
By signing you agree to all of the terms and conditions described in the COTA patient agreement and as outlined in this form. You acknowledge that you have carefully reviewed this document, and all claims submitted are valid and eligible.
Phone Number*
Best Number to reach you at if we have any questions
Email*
Please enter any additional information you would like Family Services to know in relation to this application.
Enter your name as an electronic signature*
First Last
Please use your mouse or touchscreen device to sign your name in the box below*

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Payment to Family

Transplant-Related Medical Expenses

Transplant-Related Travel Expenses

Other Transplant-Related Non-Medical Expenses

Payment Options

Direct Deposit Agreement Section

Thank you for confirming you have already setup direct deposit with COTA.

Grant Application Agreement