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Vitamin Grant Application Form
The Kansas City CF Empowerment Foundation provides financial assistance to
eligible
individuals with cystic fibrosis to help cover the cost of vitamins and probiotics. Assistance is awarded on a patient-by-patient basis and may cover up to six months of vitamins.
Patients may apply for this assistance up to two times per year.
Eligibility Criteria
Applicants must:
Be a patient at the Univerisity of Kansas Health System
Be living with cystic fibrosis
Have federally funded insurance (e.g., Medicare, Medicaid, or TRICARE)
Have no other coverage options or financial assistance available for vitamins and probiotics
Be experiencing financial hardship
1.
First and last name:
2.
Email address:
3.
Phone number:
4.
Please list your insurance coverage (primary and secondary coverage names, if applicable):
5.
Are you currently receiving any other financial assistance with your vitamins?
Yes
No
6.
If yes, where are you recieving assistance from?
7.
Which vitamins are you requesting assistance with?
8.
What barriers (other than cost) prevent you from taking your vitamins consistently?
Tase, smell, or size of vitamin
Forgetfulness
None
Other (please specify)
9.
Are you willing to report back on the use of vitamins if required by the grant?
Yes
No
10.
How would receiving this assistance improve your health or quality of life?
11.
Would you like a team social worker to follow up with you about any ongoing financial concerns?
Yes
No