The Foundation for Diabetes Education
Eligibility Application for Free Supplies

Name:  First Last Female Male
Street Address  
City   St Zip
Phone: Work   Home
E-mail    Date of Birth:

What meter do you have?

     No meter

Have you had your meter for more than 1 year? 

   Yes No   Are you on a special diet?

Doctor's name:

 Specialty:

Address:

City:

 State Zip

Phone:

 Fax: E-Mail:

Your insurance company:

 or Check if none

Are you covered by Medicare?

 Yes No

Do you have any prescription coverage?

 Yes No    If yes, please explain:
Have you applied for any of the following:

Medicaid: 

Yes No   Status:
Supplemental Security Insurance (SSI) Yes No   Status:
Social Security Disability Insurance (SSDI) Yes No   Status:

Medical Costs Worksheet

Please List all Prescription Medications your Doctor Suggested

Medication

Charge

% Paid by Insurance

Your Final Cost

$

$

 

Please List all NON-Prescription Items (supplies) your Doctor Suggested

Item

Charge

% Paid by Insurance

Your Final Cost

$

$

 

Please state the number of times you visit your Doctor each year

Visits

Charge

% Paid by Insurance

Your Final Cost

$

$

 

Please List any supplements/vitamins you take

Item

Charge

% Paid by Insurance

Your Final Cost

$

$

Please complete ONLY if you do NOT have insurance

Number of People in Household:

Monthly Household Income

for ALL Household Occupants

Earnings:

SSI:

SSDI

Pension
Alimony:
Child Support:
Unemployment:
Food Stamps:
Other:
TOTAL:

Monthly Expenses

Rent:

Food:

Utilities:

Education:

Gasoline:

Auto Payment:

Auto Insurance:

Other:

TOTAL:

 

Assets
Real Estate:
Trust Fund:
401k:
Vehicle(s):
Total:

Medical Expenses

Medical Ins.:

*Medications:

*Supplies:

In-Home Visits:

*Doctor Visits:

*Supplements:

Other:

TOTAL:

* Totals from Worksheet

Liabilities
Mortgage:
CC Debt:
Loans:
Car Loan:
Total:

Comment:

 

Authorization and Certification

I hereby authorize the Foundation for Diabetes Education to use this information to assess my eligibility for participation in the Free Diabetes Supplies Program.  I understand that this assistance is free of charge for a period of 6 months from the date of receipt of application by The FDE.  Should I wish to continue on this program, I must re-apply at any point 5 months or more from my submittal of this application.  I certify that the above statements and figures are true.

 (Signature Required) __________________________  Date: ___/___/___

Directions for Returning this Application

Print, sign, fax to:  (760) 324-7020
If any assistance is required to complete this form, please e-mail us at info@thefde.com