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 who meet these criteria: (a) Is a Singapore Citizen or Singapore Permanent Resident (b) Is aged 18 years 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 Peritoneal Dialysis (PD) at home, as certified by the attending nephrologists. 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) Psycho-social Assessment Report from Hospital s Medical Social Worker Submit all documents to: Kidney Dialysis Foundation Corporate Office Blk 333 Kreta Ayer Road, #03-33 Singapore 080333 Subsidy qualifications from KDF and Ministry of Health will be computed based on Means Testing. The treatment fee is inclusive of Goods & Services Tax for monthly PD solution packages. However, it does not include medications such as Erythropoietin, Calcijex, Venofer. For more information, please refer to the KDF PDPS Programme fact sheet. 3. KDF operates 3 Haemodialysis Centres HAEMODIALYSIS CENTRES: Bishan Centre Blk 197 Bishan St 13, #01-575/583, Singapore 570197 San Wang Wu Ti Centre Blk 333 Kreta Ayer Road, #03-33, Singapore 080333 Ghim Moh Centre Blk 6, Ghim Moh Road, #01-188, Singapore 270006 4. KDF reserves the right not to accept an application if the relevant documents are not attached with the application form and if the applicant has suppressed or given any false information. 5. The decision of KDF is final. 6. For any application enquiries, please call Patient Welfare Department at 6559 2641/2 Updated as at 02 Feb 2017
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, 并适宜在家中进行腹膜透析治疗 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) 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 Corporate Office Blk 333 Kreta Ayer Road, #03-33 Singapore 080333 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 预知更多详情, 请参考表格后侧的 KDF 腹膜透析补贴计划知识卷 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 570197 三皇五帝中心 - 大牌 333 水车路,#03-33, 新加坡 080333 锦茂中心 大牌 6 锦茂路,#01-188, 新加坡 270006 4. 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 KDF 福利部, 电话 65592641/2 询问 更新于 2017 年 02 月 02 日
APPLICATION FOR PERITONEAL DIALYSIS (PD) PORTABLE SUBSIDY PROGRAMME 肾脏透析基金腹膜透析流动津贴计划申请表格 所需要的治疗 - 请在适当的格子中打勾 PD Treatment type 腹膜透析方式 Continuous Ambulatory Peritoneal Dialysis (CAPD) 连续可携带式腹膜透析 Automated Peritoneal Dialysis (APD) 全自动式腹膜透析 Required additional 额外所需 PD Home Assessment 腹膜透析前期家访 Interim HD prior to Tenckhoff insertion Pre PD training 前期培训资助 Tenckhoff 管子植入之前短期性血液透析治疗 (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): Mr 先生 / Mrs 女士 / Mdm 夫人 / Miss 小姐 Home Address: 住家地址 NRIC No. 身份证号码 : Pink/ Blue 粉红 / 蓝 Effective Date: 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 : 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 : Marital Status: Single 未婚 / Married 已婚 / Divorced 离婚 / Highest Educational Qualification: 婚姻状况 : Separated 分居 / Widowed 鳏寡最高教育程度 : 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 / 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 看护者陪同 : 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 住宅拥有权 : Purchased / Rented 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 Occupation 职业 : Retired 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 没受雇的原因 : Taking care of family / Feeling too ill to work / Certified Medically unfit by doctor / Retrenched 照顾家庭 / 感觉虚弱 / 医生证实不适合就业 / 被裁退 Version 16-31 Jan 2017 Pg 1
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 : Insurance Co. 保险公司 HD/ PD Insurance coverage 肾脏治疗受保率 % HD/ PD Insurance coverage ceiling 肾脏治疗受保限额 $ 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 机构名称 : Holder % Dependent % 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 first dialysis from 首次洗肾是从 : (dd/mm/yyyy) Current Fee per session for Haemodialysis 目前每次血液透析治疗费用 : $ Current Fee per month for Peritoneal dialysis 目前每月腹膜透析治疗费用 : $ (G) DECLARATION 声明 - Please fill in or circle the correct information 请填入或圈出资料 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 book keeping and administration purposes ii) 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 For Civil Service Card (CSC) only 只予公务员证持有人 : (F) HISTORY OF DIALYSIS TREATMENT 洗肾治疗病例. Please fill in or circle the correct information 请填入或圈出资料 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 16-31 Jan 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 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 2 Feb2017
2 February 2017
KDF PERITONEAL DIALYSIS PORTABLE SUBSIDY (PDPS) PROGRAMME The PDPS programme which started in January 2017, aims to focus resources on making financial aid available to more needy people undergoing peritoneal dialysis (PD). In addition to administrative and social support, patients under the programme are given subsidies from the very start of their treatment. Programme Coverage: Vouchers for routine blood tests Subsidised monthly PD solution packages Subsidised Protein Supplement Subsidies for purchased medication e.g. Lanthanum Carbonate Administrative support for MOH grant, insurance and Medisave claims Social support through Renal Friends Priority for interim Haemodialysis Treatment at KDF (when required) Home Visits Home visits will be conducted by service providers Baxter and Fresenius after PD training in restructured hospitals and 1 month post training. Thereafter, the clinician only makes home visits on an ad hoc basis and/or upon request by the hospital s PD staff. Programme Eligibility KDF accepts patients with a family per capita income which does not exceed $1,800 per month. Those with higher family per capita income may be considered on a case-by-case basis. Upon referral, KDF will conduct a means test to evaluate the financial position of the patient and the subsidy that KDF can offer. Completed applications may receive outcomes within 3 weeks. TREATMENT OPTIONS Although Haemodialysis is the more commonly known method of treatment and the choice of treatment for the majority of end-stage renal failure (ESRF) patients, PD is increasingly being promoted in land scarce Singapore. KDF would like to continue to make PD an option available to patients and extend the financial help to more PD patients. In view of the limited financial resources at restructured hospitals (RH) in Singapore, the PDPS programme will benefit many needy PD patients. 2 February 2017
7412 肾脏透析基金 (KDF) 腹膜透析补贴计划 肾脏透析基金的腹膜透析 ( 洗水 ) 补贴计划在 2017 年 1 月正式启动. 此计划旨在为更多的洗水贫困病患提供资金援助. 除了行政和社交援助以外, 病患可以在加入计划后得到以下福利. 计划涵盖范围 家访 例常验血补助券 腹膜透析液月费津贴 蛋白质奶粉津贴 药物津贴, 例如 :Lanthanum Carbonate 卫生部津贴, 保健储蓄和保险申请服务 参加 肾脏之友 举办的社交活动 KDF 血液透析中心治疗的优先权 ( 若有需要 ) Baxter 和 Fresenius Medical Care 将提供医疗护理家访服务. 护理人员会在腹膜透析培训结束时, 和培训之后的一个月进行家访. 完成两次家访后, 护理人员便只会在医院或病人的要求下, 再次提供家访服务. 申请准则 KDF 会接受家庭平均收入不超过 $1,800 的申请者. 若超过 $1,800 元,KDF 将根据个别状况处理. 收到引荐之后, KDF 将为申请者测评家庭财务状况以及拟定津贴数额. 若提交完整申请表格和文件, 申请者可在三个星期内收到申请结果. 肾衰竭治疗方式 虽然血液透析模式是比较普遍的肾衰竭治疗选项, 新加坡政府正在极力推广洗水治疗以便缓和新加坡土地面积短缺的问题. KDF 也愿继续提供洗水补贴计划为更多有需要的病患伸出援手, 提供财务津贴. 鉴于公立综合医院资金有限, KDF 腹膜透析补贴计划将能帮助许多洗水的肾衰竭病患. 02-Feb-2017