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IPump.org, Inc. Diabetes Assistance Program
Eligibility Test
*** PLEASE PRINT USING BLUE OR BLACK
INK ONLY ***
Applicant
Name:
______________________________________________________________
first middle last
Who are you applying for this assistance? ____ self ____ dependent child ____ disabled spouse
1. Are you or the person you are applying for a U.S. citizen or legally residing in the United States? ___ Yes ___ No. If “no” you are not eligible for assistance through our organization.
2. Is the person who will receive assistance currently on parole? ____ Yes ____ No If “yes” see note (1)
3. Is the person to receive assistance currently or in the past twelve (12) months been a resident in any behavioral or correctional facility, or in a rehabilitation program for any form of substance abuse? ____ Yes ____ No If “yes” see note (1)
4. Have you or any member of your family received any form of assistance from IPump.org, Inc. during the past twelve (12) months? ____ Yes ____ No If “yes” you may not be eligible for additional assistance yet. Please contact us before submitting another application.
5. Can and are you willing to provide, documentation to show financial hardship, which may or may not include any of the following: insurance information, medical receipts, bills, tax returns, bankruptcy records (within the past year), paycheck or W2 employment information, and/or bank records? ____ Yes ____ No If “no” you are not eligible for our assistance.
6. Does the person to receive assistance live in a shelter, emergency housing, or rehabilitation center? ____ Yes ____ No If “yes” please submit a “Sponsored Application.”
7. Will your doctor be able to provide us with a prescription for the following items (if you plan to request these): Syringes, pen needles, pens, insulin pumps, insulin pump infusion sets and reservoirs (cartridges), any other type of insulin infusion device not listed here, LMX or other numbing cream, and/or glucagon? If “no” we will not be able to provide assistance for you for the prescription items listed in this paragraph and can only assist you with non-prescription supplies..
Sign and return completed eligibility test along with your assistance application.
Under penalty of perjury, I the undersigned swear that the above information is current, accurate, and true. Further, I understand that providing false information, or omitting information constitutes fraud, and will result in denial of any and all assistance from IPump.org, Inc. now and in the future.
_____________________________________ _______________________
Applicant Signature Date
Note (1) We do not deny applications based on simply answering “yes” to this question, however we may require additional information in order to better assist you (i.e., note from a program sponsor or note from a parole officer indicating you are not in parole violation). Before completing the remainder of the application, we suggest that you contact program-director@ipump.org to help you apply.