2025 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 an authorized pharmacies.

Guidelines

Program is limited to Cuyahoga County residents only.
Incomplete applications will NOT be accepted.
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 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.
Patient must be a U.S. citizen to qualify for assistance.
Program may be changed or discontinued at any time without notice.

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

Patient Information

Patient First Name *

Patient Last Name *

If a minor, name of parent or guardian

Date of Birth * +

Gender Identity *

Male

Female

Non-binary

Race (for reporting purposes only) *

Ethnicity (for reporting purposes only) *

Hispanic or Latino

Non-Hispanic or Latino

Are you a U.S. citizen? *

Yes

No

Street Address *

Address Line 2

City *

State *

Zip Code *

County of Residence *

Phone Number *

Email Address

Social Security Number *

Diagnosis (check all that apply) *

Who referred you to this assistance program? *

Prescription Information

Medication 1 *

Dosage per day *

Type *

Vial

Pen

Medication 2

Dosage per day

Type

Vial

Pen

Allergies

Requesting syringes and/or pen needles? *

Yes

No

How many per day? *

Prescribing Physician Name *

Physician Phone Number *

Health System Affiliation *

Transferring Pharmacy *

Pharmacy Phone Number *

Prescription Number if Available

Date Last Shipment of Insulin Received * +

Has the applicant received assistance from Kidney Foundation of Ohio in the past? *

Yes

No

Unsure

Financial Information

Are you 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

Expenses Worksheet PDF (if patient needs to complete offline)

	Applicant	Partner	Child #1	Child #2	Other	Total
Salary	Applicant	Partner	Child #1	Child #2	Other	Total
SSI/SSDI	Applicant	Partner	Child #1	Child #2	Other	Total
Pension	Applicant	Partner	Child #1	Child #2	Other	Total
Child Support	Applicant	Partner	Child #1	Child #2	Other	Total
TANF (include Ohio Works First Program)	Applicant	Partner	Child #1	Child #2	Other	Total
Food Assistance Program	Applicant	Partner	Child #1	Child #2	Other	Total
Child Tax Rebate/Tax Credits	Applicant	Partner	Child #1	Child #2	Other	Total
Unemployment Compensation/Worker's Compensation	Applicant	Partner	Child #1	Child #2	Other	Total
Short-term or long-term disability from Employer	Applicant	Partner	Child #1	Child #2	Other	Total

Total combined monthly income from all sources listed above *

Annual income (number listed above x 12) *

Total monthly income from sources NOT listed above *

If monthly income is left please, please specify why

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
Insurance Premiums (Medicare Part B, C or D, Supplemental, Commerical))	Monthly Payment Amount
Other Medical Expenses	Monthly Payment Amount
Other Expenses	Monthly Payment Amount

If Loan Payments were included, please list type

If Other Medical Expenses were included, please list type

If Other Expenses were included, please list type

Total monthly expenses from all sources listed above *

Coverage Information

Are you on Medicaid? *

Yes

No

ID Number *

Are you covered by Medicare? *

Yes

No

ID Number *

Are you covered by Medicare Part D? *

Yes

No

Plan Name *

Plan Number *

Do you have private or secondary insurance? *

Yes

No

Plan Name *

Plan Number *

Are you uninsured? *

Yes

No

Are you a Veteran? *

Yes

No

Attestation of Need

TO BE COMPLETED BY HEALTH CARE WORKER

Referring Medical Professional's Name *

Organization *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Fax Number

Email Address *

Attestation of Need

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.

*

What is the patient's plan to continue to receive their insulin in the future? *

Program Need (check all that apply) *

Provide any additional details

Healthcare Professional Signature *

clear

PROVIDE THE FOLLOWING TO PATIENT

Notice of Privacy Practices

The Kidney Foundation of Ohio will store provided information in an electronic health record which is secured, and access is limited to the staff at the Kidney Foundation of Ohio and their Affiliate Chapters. Your personal information will not be sold to any entity. Demographic information including age, race, gender, poverty guidelines and location may be provided to funding sources, but names, physical addresses and phone numbers will not be released in order to protect your privacy. If you are applying for Medication Assistance, your information, which may include name, address, phone number and date of birth, may be shared with the contracted pharmacy to fulfill prescription and/or nutritional supplement orders. You can discontinue your involvement in the direct assistance program at any time by contacting the Kidney Foundation of Ohio. All applications submitted will be retained in a locked file for a minimum of seven years.

I have provided the above Notice of Privacy Practices to my patient and the individual understands what has been provided to them. *

Yes

General Release of Information *

By signing this, I confirm that my patient is aware of and has authorized this request. I confirm that I have shared the Kidney Foundation of Ohio general release of information and notice of privacy practices with my patient.

If you would like more information about our privacy practices or have questions/concerns, please contact us.

Client Services and Community Manager: Jennifer Clegg, MSW, LISW-SUPV
Email: jclegg@kfohio.org

Telephone: (216) 771-2700
Address: 2831 Prospect Avenue, Cleveland, Ohio 44115

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