Diabetes Supply Assistance

Regular blood sugar monitoring is the most important thing you can do to manage type 1 or type 2 diabetes.

The Diabetes Foundation’s Supply Assistance program offers free supplies to children and adults living in New Jersey who are in need to ensure that you can get on track – or stay on track – with your diabetes care.

All data entered into this application will be kept confidential as the Diabetes Foundation follows HIPAA compliant best practices. If you are uploading a document with your social security number or bank account number, please black it out with a marker. We do not need this information.

"*" indicates required fields

INSTRUCTIONS: The Diabetes Foundation (DF) assists uninsured and underinsured New Jersey residents who are unable to pay for diabetes supplies due to financial hardship. DF’s Supply Assistance Program is an, emergency service that will be provided for up to sixty days to bridge the gap until a long-term solution can be obtained. DF also maintains a toll-free support network, which is available to supply recipients and others who may have questions or need ongoing resources for obtaining prescriptions, medical care, daily diabetes management, and more. The DF reserves the right to contact you with follow-up questions prior to the application being approved. Processing of applications takes place M-F 9-5. Once approved, delivery to a participant’s doorstep takes 4-7 days. If you need assistance filling this application, please call (201) 444-0337.

APPLICATION REQUIREMENTS:
  • A document displaying proof of address must be provided (i.e. copy of driver's license, utility bill, phone bill, invoice, hospital face sheet etc.).
  • Applicants must be residents of the state of New Jersey in order to receive assistance.
  • A document displaying proof of need must be provided (i.e. unemployment documentation, tax return citing no insurance, healthcare professional letter explaining need etc.).
  • Prescriptions required for syringes, pen needles, Omnipod pods, Freestyle Libre Sensors and Dexcom Transmitter and Sensors- copies are acceptable.
  • The prescriptions MUST be written for a quantity of 2 months or 60 days and dated within the past 3 weeks of application submission.
  • Copies of both sides of the applicant's insurance card(s) if they currently possess private/employer insurance, Affordable Care Act insurance, Medicare, Medicaid etc. (NOTE: This does not disqualify the applicant from the program)
*Incomplete applications will be held until al required documents have been provided*
  • Each application will be reviewed on a case-by-case basis so that DF can determine the most effective way to assist the applicant for the short-term, as well as the long-term. In some situations, applicants may be deemed as better qualified to speak directly with one of our Diabetes Resource solutions prior to receiving supplies.
PRESCRIPTION REQUIREMENTS (only needed for pen needles, syringes, Omnipod pods and CGM sensors and transmitter): • Please make sure to write prescriptions for a 60 day or 2-month supply so DF can provide 2 months of supply assistance. • Medical Facility can fax prescriptions directly to 201-444-5580 • Pictures and copies of prescriptions are accepted • Please make sure prescriptions are up to date; we will not accept prescriptions past 3 weeks of date written on prescription

1A. APPLICANT INFORMATION

Name*
Gender*

Address*
MM slash DD slash YYYY
If you do not have an email address, please put N/A
Race*

Ethnicity*
Citizenship Status*
Please note: Citizenship status does not disqualify eligibility from our program; however, it allows us to better assist you in finding long-term assistance.
Education Level of Applicant*

Preferred Language*

Name of contact if not applicant
Please confirm that the DF is able to contact the applicant or caretaker directly about their supplies or other DF services.*
Household Income*
Please note: Income does not disqualify eligibility from our program; however, it allows us to better assist you in finding long-term assistance.
Household Size*

1B. DIABETES STATUS

Type of Diabetes*
MM slash DD slash YYYY
Reason for Applying*

What is the best way to contact you?*

1C. APPLICANT INSURANCE AND HEALTHCARE DETAILS

Insurance status does not disqualify an applicant from receiving this service
Do you have insurance?*
Are you employed?*
Are you a veteran?*
Applicant under the care of a Primary Care Physican?*
Applicant under the care of an Endocrinologist?*

1D. DIABETES ANCILLARY SERVICES

The DF can provide additional free services to support better health and diabetes self-management including the following. Please check off other services we can assist with:*
Is applicant experiencing any additional stressors other than financial:*
How did you hear about our program?*

2. SUPPLY INFORMATION

Please check all supplies that you are requesting. Prescriptions are required for all syringes, pen needles, sensors, transmitters and pods.
What supplies are you in need of?*
If you do not see the supplies you use listed, please call 201-444-0337 ext. 202
To process your application DF needs proof of New Jersey residency. Please upload one of the following documents:*
To process your application DF requires proof of need. Please upload one of the following documents:*
Drop files here or
Max. file size: 24 MB.
    I verify that the information provided on this application is true and accurate. I authorize the Diabetes Foundation to use this information to assess my eligibility for participation for the supply program. I understand that this assistance will provide diabetes supplies for one time only. I certify that I do not have the ability to pay for diabetes supplies at this time and that I am in the process of applying to programs for which I may be eligible for assistance. I understand that it is at the discretion of the Diabetes Foundation that each application is approved. I authorize the Diabetes Foundation, to contact me, or my health care professional, to follow up on my progress. I give permission to my health care professional to disclose my personal information, including protected health information, to the Diabetes Foundation as it relates to this request. I understand that the Diabetes Foundation may redisclose my confidential information for the purposes of this program. I acknowledge that the Diabetes Foundation is by the Health Insurance Portability and Accountability Act (HIPPA) and will protect my confidential information and comply with all applicable federal and state laws.*
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