Veterans Caucus of the AAPA

Medical Assistance Grant Application

Veterans Caucus, Inc.

PO BOX 362
Dover, DE 19903

Medical Assistance Grant Application





Application Process

• Year round with two separate consideration periods.

• Complete online application available at www.veteranscaucus.org. Upon application completion and submission a confirmation of receipt will be sent to each applicant. Following this, only those selected will be notified of the award. Applicants not selected for Grant awards will not be notified of unsuccessful application.

• There will be two grant periods per year. At the end of each period, one (1) grant will be awarded to one (1) successful applicant

• Each Grant will be in the amount of up to $500.00, but can be less depending on need

• First Grant period is from June 1st to November 1th with the grant being awarded by November 30th

• Second Grant period is from December 1st to April 30st with the grant being awarded by Memorial Day

• Applications reviewed in order in which they are received

• Applications received past the designated grant period will be considered for the next grant period

• Application must be complete and include a copy of students DD214

• Completed applications are the property of the Veterans Caucus. Due to confidentiality, review of applications will be by members of the Veterans health committee and the Board of Directors only.

• Applications that are not considered for grant award will be destroyed following document destruction policies.

• Applications of grant awardees will be retained for one year following award and then destroyed following document destruction policies.

• Electronic application process via e-mail to Veterans Caucus Veterans Health committee Chairperson within above application periods.

Selection Process:

• By completed application to the Veterans Caucus to include but not inclusive of the following:

1. Personal statement of need which does not contain protected medical information ie diagnosis, prognosis or treatment plans

2. Statement of insurance payment gaps ie uncovered deductibles, co-payments, no coverage etc.

3. Program Director or Dean of Students review statement

4. Statement or bill of uncovered medical expenses.

5. Name, address, phone number, program/ school information

• Other objective criteria approved by the Veterans health committee and the board of directors.

• Meets all inclusion criteria and no exclusion criteria

• Grading criteria not to be released to general public to avoid compromise of integrity policy.

• All decisions made by the Veterans health committee and board of directors are final and not negotiable outside of the Board of Directors.

I understand that I am applying for a one time medical assistance Grant to cover defined eligible uncovered medical costs already incurred and wish to be considered for said grant. Permission is hereby given to officials of my institution to release information, transcripts of my academic record and other requested information by the Veterans Caucus for consideration of this grant program. I understand that this application will be available only board of director members of the Veteran Caucus of the American Academy of Physician Assistants who need to review it in the course of the selection process. I understand that once submitted, this application becomes the property of the Veterans Caucus. I attest that this application, including all contents is my own work or formally cited from other sources. I affirm that the information contained herein is true and accurate to the best of my knowledge and belief.





I. Biographical Information:




FirstName, Middle Initial(*)

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LastName(*)

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Suffix

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Email Address(*)

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Contact Street Address(*)

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Contact City(*)

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Contact State(*)

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Contact ZipCode(*)

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Contact Phone xxx-xxx-xxxx

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Contact Cell Phone xxx-xxx-xxxx

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II. PA Program Information:




Name and address of your PA Program(*)

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Program Phone(*)

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Program Director Name(*)

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Directors Email(*)

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Please supply a letter from your Program Director or Dean of Students justifying your need for medical assistance. (In pdf format)(*)

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Current Year of PA training(*)

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Please list any Honors Received(*)

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Please list any student leadership roles(*)

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III. Service Information:




Enter a pdf copy of your DD-214 here. (*)

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Honorable Discharge (*)

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Branch of Service (*)

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Component(*)

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Dates of Service(*)

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IV. Assistance Need:




Application for assistance for which family member(*)

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Current Insurance carrier(s) - please list all(*)

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Current Insurance Deductibles(*)

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Have you received any other forms of medical assistance or grants?(*)

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Have you applied for VA care?(*)

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If qualified for VA care, at what level have you been approved for(*)

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Category of uncovered medical costs(*)

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What is the total dollar amount of uncovered medical costs per category?(*)

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Please provide a statement justifying your need for this assistance. (Maximum 300 word) Accepted formats: .pdf(*)

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V. Additional Information:




Is there any additional information (not already addressed in the application) that you wish to share with the Veterans Health Committee members that may be beneficial for grant selection?(*)

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