Julie Love Diabetics Assistance Program
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.Online Application
 
Please answer these short questions so we can best determine if you're qualified for this program. All of these questions are *required
*What is your name:
*What is your age:
*What is your Sex:
*What is your email address :
*What is your home phone :
*What is your mobile phone :
*What is your street address :
*Apt #
*What is your state of residence :
*What is your zipcode :
*What is your yearly household income :
 (ex. $12,500)
*How many people are in your household
*Are you pregnant

*Are you eligible for any of the following?
(Please check all that apply)

  
If "Medicare" or "Medicaid" is checked above:

If eligible, are you currently receiving Medicare?
Yes    No

If question above was answered with "yes":

Do your total assets exceed $11,500 for an individual or $23,000 for a married couple living together?
Yes    No


If eligible, are you currently receiving Medicaid?
Yes     No

Do you participate in the Medicare Savings Program, otherwise known as the Qualified Medicare Benefit or QMB or the Special Low Income Medicare Benefit or SLIMB?
Yes     No

 
* Are you eligible for prescription drug coverage for the medications you previously selected?
Yes     No 		 
* What is your current residency status?

U.S. Citizen
Legal Resident of the U.S.
Other
  
Have the recent hurricanes affected your ability to get access to your prescription medications or diabetic equipment and supplies?
Yes    No 		 
How did you hear about JulieLove.org?  
 

 

2006 Copyright - Julie Love Assistance Program For Diabetics, Inc. a 501(c)(3) organization