IBC CHARITABLE MEDICAL CARE GRANT PROGRAM

Grant Application The Independence Blue Cross (IBC) Charitable Medical Care (CMC) Grant Program awards financial support to nonprofit, privately funded health clinics in southeastern Pennsylvania that provide free or nominal fee direct medical care to the uninsured and/or underinsured. This commitment makes grants available through 2010 to support areas such as general operating expenses, medical equipment and supplies, clinical staff, specialty care, diagnostic tests, or other pertinent needs critical to the delivery of service. The need for requested funding must be clearly demonstrated in this application. IBC will gladly consider multi-year grant requests for funding through 2010. However, awards of multi-year grants will be disbursed annually and only after a satisfactory review of required reporting. Grant requests are reviewed by the IBC Charitable Medical Care Grant Committee.

The DEADLINE to submit the completed grant application and all supporting documents to be considered for 2008 grant funding is Friday, November 21, 2008. *If we receive your application after this date, your request will be put on hold for consideration in 2009.

CMC Grant Application Contents Grant Application Cover Summary………………………………………………...pages 2 – 4 Grant Application Narrative – Description of Grant Purpose……………………page 5 List of Supporting Documents………………………………………………………page 6 Please submit the completed CMC grant application electronically to [email protected]. Supporting documents in hard copy can be sent through regular postal service addressed to: Courtney Smith Social Mission Program Analyst Independence Blue Cross 1901 Market St., 28th floor Philadelphia, PA 19103 Please contact Courtney Smith for more information: Phone: 215.241.4862 E-mail: [email protected] Fax: 215.241.3543 www.ibx.com\social_mission

CHARITABLE MEDICAL CARE GRANT PROGRAM – Grant Application Instructions

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IBC CHARITABLE MEDICAL CARE GRANT PROGRAM Grant Application Cover Summary I. Organizational Overview 1.) Please provide the following details about your organization: Legal Name of Organization: Address: Name of Clinic: Clinic Address: Name of Executive Director: Name of President of Board: Total number of Board Members: Federal ID number: Grant Requestor Contact Name / Title: Phone:

Fax:

Email:

Web Address:

2.) IRS 501c(3) nonprofit? YES If YES, please attach copy of designation letter from IRS. 3.) End of year income:

End of year expenses:

4.) Total annual operating budget:

Dates of fiscal year:

5.) List top three private donors (business and foundation) and the amounts they have contributed: Company/Individual Donor Name:

Term of grant (Start/End Date):

Amount contributed:

6.) Does your organization receive support from United Way or any other federated funds? YES If YES, percentage of total operating budget supported by these entries: %

7.) Does your organization receive government support of any kind? YES If so, list the amount and sources:

8.) State your organization’s mission:

CHARITABLE MEDICAL CARE GRANT PROGRAM – Grant Application Cover Summary

(3) II. Summary of Charitable Medical Care Grant Proposal 1.) Total grant amount requested (through up to 2010): Year 1: 2008

Year 2: 2009

Year 3: 2010

Total Amount Requested through 2010

Total number of years: 1 year 2.) Period to cover this renewal request (month / year):

/

to

/

3.) Summarize the purpose of the grant request (including the name of the program, if applicable):

4.) List the proposal’s target population, constituents, and geographic communities:

III. Description of Clinic Operations 1.) Describe the delivery model of your clinic. (Volunteer physician, Certified Registered Nurse Practitioner, etc.)

2.) Does your clinic currently utilize an electronic medical record (EMR) system? Yes 3.) Please specify the total number of staff currently employed by your clinic. Clinical:

Full-time:

Part-time:

Volunteer:

Administrative:

Full-time:

Part-time:

Volunteer:

4.) List all current services and programs provided by your clinic, as well as any key affiliations with other hospitals or health care providers: Services Provided Onsite: Primary Care Dental Care Behavioral Health and Counseling

Social Work Pharmacy Program Other (please specify all):

Programs: Key Affiliations:

CHARITABLE MEDICAL CARE GRANT PROGRAM – Grant Application Cover Summary

(4) 5.) Please specify your weekly clinical hours for the 2008 calendar year. *If clinical hours vary by program, please specify the weekly clinical hours provided by each program. Mon.

Tues.

Wed.

Thurs.

Fri.

Weekend

Total Daily Clinical Hours *Primary Care *Other: *Other:

Total Clinical Hours / Week =

6.) Are there any eligibility requirements a patient must meet in order to receive care at your clinic? If you answered ‘yes,’ please describe these requirements:

7.) Is your clinic a participating provider with any health insurers? If so, please specify which Health Plans:

YES

YES

8.) Please specify the insurance status of patients served (percentage): Government/Medical Assistance: % Uninsured: %

Other:

%

9.) Does your clinic facilitate applications for clients eligible for government or private programs? If so, please describe.

YES

IV. Patient Data – Direct Care Services Please use the grids below to summarize your clinic’s patient data for calendar year 2007 and the first half of 2008. This will capture the impact that your clinic has made on the community and enable us to measure any future improvements made by your team. Calendar Year 2007

Jan 1 – June 30, 2008

Total Patients (unduplicated) Primary Care Patients Dental Patients Other (please indicate)

Total Visits** Primary Care Services Dental Services Other (please specify)

**Total visits can be defined as total number of duplicate patients Additional details/comments: (optional) CHARITABLE MEDICAL CARE GRANT PROGRAM – Grant Application Cover Summary

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IBC CHARITABLE MEDICAL CARE GRANT PROGRAM Grant Application Narrative – Description of Grant Purpose Please provide the following information in this order. Do not use more than 3 pages, exclusive of attachments. I. Needs Assessment Describe the situation – opportunity, problem, issue, need, and the community – that your proposal addresses, and how that need was determined.

II. Goals and activities State the key objectives of your grant proposal. Provide a description of the measurable activities through which you will accomplish each objective. - Who will carry out these activities (if this is a collaboration, briefly describe the partners). - Explain how the proposed activities will impact the designated community or population.

III. Evaluation Explain how you will measure success in achieving your objectives. - What methods will be used to evaluate the effectiveness of activities (criteria, data, instruments, analysis)? How will your results be used, disseminated, or publicized?

Date submitted:

CHARITABLE MEDICAL CARE GRANT PROGRAM – Grant Application Narrative – Description of Grant Purpose

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IBC CHARITABLE MEDICAL CARE GRANT PROGRAM List of Supporting Documents Please submit the following information along with the completed application in the order below. I. Organizational Information

Please provide the following descriptions in 2 pages or less: 1. Brief summary of Organization’s history. 2. Description of current programs, activities, strengths/accomplishments, and challenges faced by your organization (highlighting the past year). II. Financial Information

For ALL grants, please submit the following information: 1. Itemized budget for how this specific grant will be used. Identify each source of revenue, the amount, and whether funds are either committed or pending. If request is for a multi-year grant, include multi-year program budget. 2. Annual operating budget and actual income and expenses for most recently completed fiscal year AND for current year-to-date. 3. Organization’s most recent AUDITED financial statement (if budget greater than $100,000) or Form 990 (if budget between $25,000 and $100,000). If neither document is available, include unaudited financial statements. III. Other Supporting Materials

1. 2. 3. 4. 5.

Latest annual report or summary of the organization’s prior year activities. Current board list with members’ employment affiliations, constituencies, and years served. An organizational chart (if applicable) and a one-paragraph description of key staff. Letters of agreement from any collaborating or affiliated agencies, if applicable. Letters of support and/or recent reviews or articles, if available.

Please submit the completed CMC Grant application electronically to [email protected] Supporting documents and materials in hard copy format can be sent through regular postal service to the following address: Courtney Smith Social Mission Programs Analyst Independence Blue Cross 1901 Market St., 28th floor Philadelphia, PA 19103

For more information, please contact Courtney Smith: Phone: 215.241.4862 E-mail: [email protected] Fax: 215.241.3543 www.ibx.com\social_mission

CHARITABLE MEDICAL CARE GRANT PROGRAM – List of Supporting Documents