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1 APPLICATION FOR SUBSIDISED DIALYSIS PROGRAMMES Qualifying Criteria 1. Kidney Dialysis Foundation s (KDF) subsidized dialysis programmes are open to end-stage kidney patients who: (a) Is a Singapore Citizen or Singapore Permanent Resident (b) Is aged18 years old and above (c) Applicant family s monthly per capita income not exceeding $1,800 would be considered. Should the applicant family s monthly per capita income exceed $1,800, KDF will assess these applications on a case-by-case basis. (d) May have any other co-morbid conditions but is rendered safe to undergo Haemodialysis (HD) in a community-based satellite HD centre, as certified by the attending nephrologists (for HD applicant only). Process of Application 1. All sections in the application form must be completed. N.A. should be used where appropriate. 2. All applicants are required to submit the following documents: (a) Applicant s latest pay-slip or letter from employer stating current gross income, CPF statement, and Income Tax Statement (b) Applicant s family members latest pay-slip or letter from employer stating current gross income or CPF statement or Income Tax Statement (c) A recent passport-sized photograph (d) A copy of applicant s identity card (e) A copy of any financial assistance from other agencies or Public Assistance Card (if applicable) (f) A copy of Hospital Medical Report (includes latest ECG, Hepatitis, HIV, and Chest X-ray results) from applicant s renal doctor. Please include Echo or Muga scan report if necessary (g) Psycho-social Assessment Report from Hospital medical social worker Submit all documents to: Kidney Dialysis Foundation Blk 333 Kreta Ayer Road, #03-33 Singapore Subsidy qualifications from KDF and Ministry of Health will be computed based on Means Testing. The treatment fee is inclusive of Good Service Tax, routine blood test and doctor s consultation. However, it does not include medications such as Erythropoietin, Calcijex, Venofer. Needy patients with mobility issues may be given one way transport subsidy on a case- by- case basis, in the form of a cab charge card, up to a maximum of $20 per treatment session. Request may be made to Patient Welfare after admission into KDF programme. 3. KDF operates 3 Haemodialysis Centres: Bishan Centre Blk 197 Bishan St 13, #01-575/583, Singapore San Wang Wu Ti Centre Blk 333 Kreta Ayer Road, #03-33, Singapore Ghim Moh Centre Blk 6, Ghim Moh Road, #01-188, Singapore KDF reserves the right not to accept an application if the relevant documents are not attached with the application form or if the applicant has suppressed or given any false information. 5. The decision of KDF is final. 6. For any application enquiries, please call /2 Updated as at 19 Jan 2017

2 肾脏透析基金受津贴洗肾治疗申请申请准则 1. 肾脏透析基金 (KDF) 的受津贴洗肾治疗计划正开放给符合以下条件的末期肾衰竭病患者申请 : (a) 新加坡公民或新加坡永久居民 (b) 年龄在 18 岁以上 (c) 家庭平均收入不得超过 $1,800 元申请者的家庭平均收入若超过 $1,800 元,KDF 将根据状况各别处理 (d) 已由肾科医生证实没有其他相关病症会影响血液透析治疗, 并适宜在设于社区的卫星中心接受血液透析治疗 ( 只限血液透析申请人 ) 申请程序须知 1. 必须完整填写申请表格中的每一个栏 N.A 请酌情使用 2. 所有申请者在提交申请表格时必须同时附上以下证件 : (a) 申请者的薪酬报单或由雇主证实现有薪酬的信件, 公积金报单和所得税报单 (b) 申请者家属的薪酬报单或由雇主证实现有薪酬的信件或公积金报单或所得税报单 (c) 近期的照片一张 ( 护照照片的尺寸 ) (d) 申请者身份证复本 (e) 经济上受助于任何组织的复本或公共援助卡的复本 ( 如果适用 ) (f) 申请者的肾科主治医生的医药报告复本 ( 包括最近的心电图肝炎 HIV 及胸部 X 光照 ) 如果有 Echo 和 Muga 扫描报告, 也请提交 (g) 由医院的医药社工所评定的社会心理报告请将表格及所有证件提交到 : Kidney Dialysis Foundation Blk 333 Kreta Ayer Road, #03-33 Singapore KDF 与卫生部的津贴数额将根据支付能力的调查方程式来计算治疗费用包括消费税医生复诊费和例常血液检验的费用, 但不包括任何药物, 如红血球生成剂活性维生素 D 剂糖铁注射剂行动不方便人士, 可以成为本基金病患者之后, 向福利部申请单方向行程德士津贴卡. 申请成功与否, 津贴数额 ( 顶限为 $20 一次行程 ), 将根据各别情况而定. 3. KDF 共经营三所血液透析治疗中心 : 碧山中心 - 大牌 197 碧山 13 街,#01-575/583, 新加坡三皇五帝中心 - 大牌 333 水车路,#03-33, 新加坡锦茂中心大牌 6 锦茂路,#01-188, 新加坡若在提交申请表格时没有一起附上有关的证件有所隐瞒或给予任何不确实的资料,KDF 有权不接受申请 5. KDF 拥有最终的决定权 6. 欲知更多详情, 请拨电话 /2 询问更新于 2017 年 01 月 19 日

3 APPLICATION FOR SUBSIDISED DIALYSIS PROGRAMME 肾脏透析基金津贴计划申请表格 (A) PREFERRED DIALYSIS SCHEDULE 优选的治疗时段. Please circle desired dialysis shift and timing 请圈出需要的时段 Monday 周一, Wednesday 周三,Friday 周五 / Tuesday 周二, Thursday 周四, Saturday 周六 Morning 早晨 7 am / Afternoon 中午 12 noon / Evening 傍晚 5 pm (B) PERSONAL PARTICULARS 个人档案. Pls fill in or circle the correct information 请填入或圈出资料 Name 姓名 (Underline Surname): NRIC No. 身份证号码 : Effective Date: Mr 先生 / Mrs 女士 / Mdm 夫人 / Miss 小姐 Home Address: 住家地址 Pink/ Blue 粉红 / 蓝 Office Tel 办公室电话号码 : Sex 性别 : Male 男 / Female 女 Postal Code 邮区号码 : Home Tel 住家电话号码 : HP 手提电话 : Attach a recent passport photograph 请附贴一张近期的照片 Age 年龄 : Date of Birth: (dd /mm /yyyy) Nationality 国籍 : Race: Chinese / Malay / Indian 种族 : 华族 / 马来族 / 印度族 Others please specify: 其他请注明 : Marital Status: Single 未婚 / Married 已婚 / Divorced 离婚 / 婚姻状况 : Separated 分居 / Widowed 鳏寡 Language 语言 / Dialect Spoken 方言 : English 英语 / Mandarin 华语 / Malay 马来语 / Tamil 淡米尔语 / Cantonese 粤语 / Hokkien 厦语 / Religion: Buddhist/ Christian / Muslim/ Hindu 宗教 : 佛教 / 基督教 / 回教 / 兴都教 Others please specify: 其他请注明 : Highest Educational Qualification: 最高教育程度 Language Written 语文 : English 英文 / Chinese 华文 / Malay 马来文 / Tamil 淡米尔文 / Others 其他 Teochew 潮语 / Hakka 客语 / Others 其他 Mobility Status 行动能力 : Wheelchair 需要轮椅 / Assistance required 需要人协助 / Independent 独立自行 Care Giver presence for dialysis session 看护着陪同 : No 没有 / Yes 有 Type of residential property: HDB Flat Rooms / HDB Executive / HDB Maisonette / HUDC / Private Apartment / Terrace House / Semi-Detached House/ Bungalow / Shop House 住宅类别 : 政府组屋房式 / 共管式公寓 / 私人公寓 / 私人排屋 / 私人独立式屋 / 店屋 Ownership of residential property: Purchased / Rented 住宅拥有权 : 自购 / 租用 Nature of rent: 1 / 2 / 3 / 4 / 5 Room (s) / Whole flat / Whole pte Apartment / Whole house 租用性质 : 1 / 2 / 3 / 4 / 5 间房间 / 整间组屋单位 / 整间公寓单位 / 整间房屋 (C) EMPLOYMENT INFORMATION 雇用资料. Pls fill in or circle the correct information 请填入或圈出资料 Employed Full-Time 全职 / Employed Part-Time 兼职 / Retired Occupation 职业 : 退休 / Unemployed 没受雇 Name of Company 公司名称 : Company Address 公司地址 : Gross Monthly Salary 月薪总额 : Date Joined 聘用日期 : If unemployed, pls indicate reason for unemployment: Taking care of family / Feeling too ill to work / Certified Medically unfit by doctor / Retrenched 没受雇的原因 : 照顾家庭 / 感觉虚弱 / 医生证实不适合就业 / 被裁退 Version March 2017 Pg 1

4 APPLICATION FOR SUBSIDISED DIALYSIS PROGRAMME 肾脏透析基金津贴计划申请表格 (E) FINANCIAL INFORMATION 财务状况. Pls fill in or circle the correct information 请填入或圈出资料 Medical Insurance Coverage 医药保险 : Medisave 保健储蓄 : a) Medishield Life 终生健保双全 : b) Incomeshield 英康保健 : Plan A 计划 / Plan B 计划 / Plan C 计划 c) Others (please specify) 其他的保险 : No 没有 / Yes 有, Amount 存额 : $ Financial help from other charity/ government agencies 其他慈善 / 政府机构给于的经济援助 : No 没有 / Yes 有 Amount 存额 : $ per month 每月 Name of organization 机构名 : Insurance Co. 保险公司 HD/ PD Insurance coverage 肾脏治疗受保率 % For Civil Service Card (CSC) only 只予公务员证持有人 : HD/ PD Insurance coverage ceiling 肾脏治疗受保限额 $ Holder % Dependent % (F) HISTORY OF DIALYSIS TREATMENT 洗肾治疗病例. Pls fill in or circle the correct information 请填入或圈出资料 Name of Doctor 医生姓名 : MSW 社工 From 医务处 : SGH 中央医院 / NUH 国大医院 / NGTFH 黄廷芳综合医院 / TTSH 陳篤生医院 / KTPH 邱德拔医院 / AH 亚历山大医院 / CGH 樟宜综合医院 / Private Centre 私营中心 (please specify 请注明 ) Currently receiving HD treatment at 正在何处接受血液透析治疗 : SGH 中央医院 / NUH 国大医院 / NGTFH 黄廷芳综合医院 / TTSH 陳篤生医院 / KTPH 邱德拔医院 / AH 亚历山大医院 / CGH 樟宜综合医院 / Private Centre 私营中心 (please specify 请注明 ) Started from 开始日期 : Current Fee per session 目前每次治疗费用 : $ Current dialysis schedule: 目前血液透析治疗时程表 (please select either days 135 or days 246 请选周 135 或 246): Monday 周一, Wednesday 周三,Friday 周五 / Tuesday 周二, Thursday 周四, Saturday 周六 Current treatment timing 目前治疗时段 (please select 1 of 3 timings 请选 1 个时段 ): Morning 早晨 7 am / Afternoon 中午 12 noon / Evening 傍晚 5 pm I give consent to Kidney Dialysis Foundation (KDF) to provide my personal information to third-parties for the sole purpose of providing dialysis services. I fully understand and agree that the personal information which I have provided may be disclosed to other agencies or individuals for the purpose(s) stated below. I trust that the information will strictly be used for the purpose(s) stated: i) Personal particulars for KDF s bookkeeping and administration purposes ii) iii) History of dialysis treatment to ensure the appropriate medical care is provided Accommodation, Employment and Financial information for means-testing purposes. 本人同意肾脏透析基金为提供透析或相关的服务, 而向第三者透露这表格上的资料本人明白与同意, 相关的第三者可能因为行政管理, 账目管理, 医疗护理, 测评津贴数额等等, 需要获知与利用表格上的资料. I declare that the information given by me in this application form is true and complete. In addition, I declare that I am not / I am affiliated (please delete where appropriate) to any staff / board member in Kidney Dialysis Foundation or do not have/ have a direct or indirect interest in any business transaction(s), agreement, and investment with Kidney Dialysis Foundation. 本人宣誓在这申请表格中所提供的资料是正确及真实的本人与肾脏透析基金的职员或董事会成员没有 / 有从属关系业务交易协议及投资相关的直接或间接地利益关系 I fully understand and accept that if at any time, it is found that a false declaration has been made in this form; the Kidney Dialysis Foundation (KDF) reserves the absolute right not to accept my application or withdraw my subsidy or cease my dialysis treatment at KDF. 本人明白并接受在任何时候若发现此表格中所做的宣誓有所虚假, 肾脏透析基金 (KDF) 保有绝对的权利终止本人在其中心的洗肾治疗计划 Name of Applicant 申请者姓名 Signature 签名 Date 日期 Version March 2017 Pg 2

(D) FAMILY INFORMATION 家庭成员资料 Name of Immediate Family 直属家庭成员姓名 Staying with applicant (Yes/No) 与申请者同住 ( 是 / 否 ) Relationship to Applicant 与申请者的亲属关系 NRIC Number 身份证号码 Date of Birth 出生日期 Marital

5 (D) FAMILY INFORMATION 家庭成员资料 Name of Immediate Family 直属家庭成员姓名 Staying with applicant (Yes/No) 与申请者同住 ( 是 / 否 ) Relationship to Applicant 与申请者的亲属关系 NRIC Number 身份证号码 Date of Birth 出生日期 Marital Status 婚姻状况 No of children 子女人数 Occupation (Designation) 职业 ( 职位 ) Gross Monthly Income 月薪毛数 Total Income 收入总数 : In case of emergency, please contact 紧急状况时请联络 Name 姓名 : Address 地址 : NRIC No. 身份证号码 : Relationship Contact No. (H) 住家电话 : Contact No. (HP) 手机电话 : (S) Updated as at 7 Dec 2016

APPLICATION FOR HAEMODIALYSIS PROGRAMME

APPLICATION FOR HAEMODIALYSIS PROGRAMME APPLICATION FOR PERITONEAL DIALYSIS PORTABLE SUBSIDY PROGRAMME Qualifying Criteria 1. Kidney Dialysis Foundation s (KDF) Peritoneal Dialysis Portable Subsidy programme is open to end-stage kidney patients