2024 Emergency Insulin Program

Overview
Approved applicants can receive an emergency supply of insulin, syringes, or pen needles. The program is available one-time only, and when no other assistance is available. The applicant will be notified by phone of approval or denial of the request. Approved individuals will receive supplies from one of two authorized pharmacies.

Guidelines

Program is limited to Cuyahoga County residents only.
Assistance from this program is available one-time only. A patient is not eligible a second time.
The Kidney Foundation of Ohio’s ability to assist individuals 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.
Program may be changed or discontinued at any time without notice.

For questions, contact (216) 771-2700 or programs@kfohio.org.

Patient Information

Patient First Name *

Patient Last Name *

If a minor, name of parent or guardian

Date of Birth * +

Gender *

Male

Female

Non-binary

Ethnicity (for reporting purposes only) *

Street Address *

Address Line 2

City *

State *

Zip Code *

County of Residence *

Phone Number *

Email Address *

Social Security Number *

Diagnosis (check all that apply) *

Prescription Information

Name of Medication *

Type *

Vial

Pen

Dosage (units per day) *

Allergies

Requesting syringes and/or pen needles? *

Yes

No

How many per day? *

Prescribing Physician *

Physician Phone Number *

Health System Affiliation *

Transferring Pharmacy *

Pharmacy Phone Number *

Prescription Number if Available *

Date Last Shipment of Insulin Received * +

Coverage Information

Is patient on Medicaid? *

Yes

No

ID Number *

Is patient covered by Medicare? *

Yes

No

ID Number *

Is patient covered by Medicare Part D? *

Yes

No

Plan Name *

Plan Number *

Does patient have private or secondary insurance? *

Yes

No

Plan Name *

Plan Number *

Is patient a Veteran? *

Yes

No

Is patient uninsured? *

Yes

No

How were you referred to the program? *

Patient Financial Information

Presently Employed? *

Yes

No

Household Members *

Self

Spouse/Partner

Dependents

List all dependents, and ages, living in household (adults, children, grandchildren, etc.)

+-

Monthly Household Income *

	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Salary	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
SSI/SSDI	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Pension	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Child Support	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
TANF (include Ohio Works First Program)	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Food Assistance Program	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Child Tax Rebate/Tax Credit	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Unemployment Compensation	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total
Other Assistance	Applicant	Spouse/Partner	Child #1	Child #2	Other	Total

Total combined monthly income from all sources listed above *

Annual income (number listed above x 12) *

Monthly Expenses *

	Monthly Payment Amount
Medication (out of pocket cost only)	Monthly Payment Amount
Rent/Mortgage	Monthly Payment Amount
Utilities (combined monthly average)	Monthly Payment Amount
Groceries	Monthly Payment Amount
Transportation (bus fare, gas, taxi, Uber/Lyft)	Monthly Payment Amount
Insurance	Monthly Payment Amount
Car Payment	Monthly Payment Amount
Entertainment	Monthly Payment Amount
Telephone (include cell phone)	Monthly Payment Amount
Tuition/Education (include Student Loans)	Monthly Payment Amount
Other Loan Payments	Monthly Payment Amount
Credit Card Payments (total per month)	Monthly Payment Amount
Doctor/Hospital (copays, deductibles, out of pocket)	Monthly Payment Amount
Medicare (Premiums, Part B, Supplemental)	Monthly Payment Amount
Other Medical Expenses	Monthly Payment Amount
Other Expenses	Monthly Payment Amount

Total monthly expenses from all sources listed above *

Assessment

TO BE COMPLETED BY SOCIAL WORKER, NURSE, OR PHYSICIAN.

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

Professional Assessment *

Program Need (check all that apply) *

Additional Details *

Referring Medical Professional's Name *

Organization *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Fax Number *

Email Address *

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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