American kidney foundation patient profile worksheet 2025

1. Click ‘Get Form’ to open the American Kidney Foundation Patient Profile Worksheet in our platform.
2. Begin with Part 1: Dialysis Center Information. Fill in the facility name, number, corporate affiliation, and address details. Ensure you provide accurate contact information for the renal professional.
3. Move to Part 2: Patient Information. Enter your Social Security Number, date of birth, and personal details including your mailing address and gender. This section is crucial for identifying your profile.
4. In Part 3: Additional Information, select your marital status and employment status. Provide details about your kidney diagnosis and treatment modality by checking the appropriate boxes.
5. Proceed to Part 4: Request for Assistance. Indicate your eligibility for Medicare or Medicaid and explain any benefits you receive.
6. Complete Part 5: Patient Financial Information by detailing household assets and monthly expenses. This information is vital for assessing financial assistance needs.
7. Finally, sign in Part 6: Patient and Renal Professional Signature Confirmation to validate your application before submitting it through AKF’s Grants Management System.

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