The Epilepsy Therapy Project (ETP) has developed this program to provide financial assistance to individuals with limited financial resources who have been accepted for enrollment in any IRB-approved clinical trial of an epilepsy therapy and who has signed an informed consent form for the trial. Funding will be made available to help cover out-of-pocket costs associated with participation in these clinical trials. Eligible expenses for reimbursement will include travel expenses to the study site and co-payments, deductibles, and co-insurance required by the patient's health plan.

Eligibility

• Applicants must complete a "Request for Financial Assistance Application" that includes information about the applicant's financial resources available to support clinical trial participation.
• The principal investigator of the applicable clinical trial must sign the application in order to verify that the patient has been accepted into the clinical trial and has given informed consent in accordance with the approved study protocol.
• The Epilepsy Therapy Project will evaluate the applicant's financial need in accordance with ETDP guidelines. Generally, eligible individuals will have net income that does not exceed 300% of the federal poverty level. Unusual circumstances may be considered in determining eligibility.
• Generally, the fund will assist the patient with his or her own participation-related expenses only.
• Original receipts (e.g., Explanation of Benefits from health plan; travel expense receipts) are required for reimbursement of expenses.

Program Guidelines

• The maximum amount that will be awarded per individual will be $5,000 per two-year period.
• Reimbursement will be provided only for the patient's out-of-pocket costs that are not covered by his or her health insurance, Medicare, Medicaid, other federal or state assistance program, or the study sponsor as detailed in the clinical trial's informed consent form. These expenses are anticipated to include co-payments, deductibles, co-insurance, and travel expenses.
• Funds will be awarded to eligible individuals on a first come, first-served basis to the extent that funding is available. Donors to the Patient Assistance Fund or persons related to donors will not receive preferential treatment.
• After an applicant has been notified of his or her acceptance for financial assistance, eligible expenses may be submitted for reimbursement by completing a "Request for Reimbursement of Expenses" form and sending the form along with original receipts to the address below. It is not necessary to complete a new application each time that reimbursement is requested within the two-year award period.
• The following travel expenses will be eligible for reimbursement:
• Air, rail, or bus fare or mileage; lodging; parking and tolls; up to $30 per day for reasonable meal expenses.
• Applications and requests for reimbursement may be submitted to:
  
  Epilepsy Therapy Project
  Attn: Patient Assistance Fund
  P.O. Box 742
  Middleburg, Virginia 20118
  540.687.8066 (fax)
  

For additional information about this program, please call 540.687.8077

• Download Request for Financial Assistance Application (PDF)

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