2024 Medication Assistance Program

This program is based on the amount of funding available and is limited to the Foundation’s thirty-seven county service area. The program provides financial aid to help individuals purchase renal medications or nutritional supplements through an approved pharmacy. If approved, a renewal form must be submitted by July 1st to maintain funding on program. Priority is given to people who are uninsured or underinsured.


  • Application must be submitted by a healthcare professional.
  • Medication assistance cannot be awarded in conjunction with transportation assistance.
  • The Kidney Foundation of Ohio’s ability to assist patients is based on the availability of funds. An application for assistance is not a guarantee of acceptance or “entitlement” to services.
  • U.S. Federal Poverty Guidelines will be used to determine the patient’s level of eligibility. Intentionally misleading information on the application is cause for denial of assistance.
  • There is a minimum two-week review process for all applications.
  • Programs may be changed or discontinued at any time without notice.
For questions, contact (216) 771-2700 or programs@kfohio.org.

Patient Information

Gender Identity *
Race (for reporting purposes only) *
Ethnicity (for reporting purposes only) *
Diagnosis (check all that apply) *
Mode of Treatment (check all that apply) *
Requesting nutritional supplements? *
If requesting Nutritional Supplements, a Nutritional Supplement Form will need to be uploaded below.

Requesting Medication Assistance for a patient in Summit County? *
What is the preferred pharmacy? *
To receive a FREE ID Band for patient, select their access location:

Healthcare Professional Information

What is your discipline? *

Patient Financial Information

Is patient presently employed? *
Household Members *
List all dependents, and ages, living in household (adults, children, grandchildren, etc.)
Monthly Household Income *
 ApplicantSpouse/PartnerChild #1Child #2OtherTotal
Child Support
TANF (include Ohio Works First Program)
Food Assistance Program
Child Tax Rebate/Tax Credit
Unemployment Compensation
Other Assistance
Monthly Expenses *
 Monthly Payment Amount
Medication (out of pocket cost only)
Utilities (combined monthly average)
Transportation (bus fare, gas, taxi, Uber/Lyft)
Car Payment
Telephone (include cell phone)
Tuition/Education (include Student Loans)
Other Loan Payments
Credit Card Payments (total per month)
Doctor/Hospital (copays, deductibles, out of pocket)
Medicare (Premiums, Part B, Supplemental)
Other Medical Expenses
Other Expenses

Coverage Information

Is patient on Medicaid? *
Is patient covered by Medicare? *
Is patient covered by Medicare Part D? *
Is patient enrolled in LIS (Limited Income Subsidy/Extra Help)? *
Does patient have private or secondary insurance? *
Is patient uninsured? *
Is patient a Veteran? *

Attestation of Need


Provide as many details as possible. Funding is allocated to individuals who demonstrate the most need.  Include the circumstances behind the applicant’s request. 


Acceptable:  Client is unable to work due to dialysis treatments.  They are requesting assistance because their copays for medication is a burden to them.  The client has been unable to purchase necessary medications for 3 months. DO NOT USE THIS EXAMPLE.

Unacceptable:  Client is applying for assistance due to financial hardship

Required Additional Data


Information provided to be utilized solely for program evaluation purposes.

If provided assistance, how would funds be applied? (check all that apply) *
Did patient receive funding from the Kidney Foundation of Ohio's Medication Assistance Program in 2023? *
Is the patient able to afford all prescribed medications or nutritional supplements? *
A current medication list will need uploaded (as a word document or PDF), or can be listed individually within this form. Please select how you could like to provide a current medication list. *
List current medications. Include both prescription medications and over the counter medications. *

At this time, you can Save Progress and finish completing the application at another time or select Next to sign and submit the application.

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