Dear Diabetes - Assistance

Visit our Resources page for links to additional assistance programs and websites.

Guidelines for Financial Assistance

A diabetic individual requiring a gift of financial assistance which will facilitate the quality of life for the individual and their family.
A gift must directly benefit the individual by assisting with medical expenses and daily living expenses, as they need to keep their daily life as normal as possible.
Financial assistance provided by Dear Diabetes is made possible because of generous donors. It is important that these funds be available for families and individuals experiencing the greatest financial need. There is no income limit but we want to help those in the greatest of need that are unable to do so on their own. Each application is looked at individually.
Preferential consideration is given to applicants residing in the Omaha area.
All sections of the application must be completed thoroughly and accurately in order for Dear Diabetes to review the request. Failure to provide complete and truthful information is a basis for denial.
Financial assistance is not guaranteed and is subject to the availability of funds. Awards are made at our annual fund raiser held in September. If you have a need prior to the fund raiser, please visit our website for additional resources in the Omaha area. We have partners who are willing to assist you and your family with your financial needs.
All financial applications will be reviewed on a case-by-case basis. Funds will be payable to the organizations you owe so as not to impact your taxable income. Consideration will be given based on taxable income, your medical burden, and the number of family members in the household.
The information you provide to us will be held in confidence and used only in appropriate ways consistent with the reasons for which it was provided.

To apply for financial assistance, please complete the application form below or Click here to email us.

Application for assistance form

Assistance Form

HEALTHCARE PROFESSIONAL

Doctor, or Hospital Patient Navigator/Social Worker

Healthcare Professional Name

Hospital/Clinic

Address

City

State

Zip Code

Phone

If diabetes has prevented you from working - List annual lost wages

What type of accommodations do you need? such as Service animal, transportation, wheel chair

Do you have other medical conditions resulting from diabetes or impacting your ability to manage your diabetes?

HOUSEHOLD FINANCIAL INFORMATION

Please do not leave any information blank

Are you currently:

Employed

Retired

Student

Other

Other - please explain

Number of immediate family members in the household

Please list family members below - Use + sign to add more than 1 member

Name	DOB	Relationship

Monthly Household Income Sources (please list all that apply)

Salary

Pension

Social Security (retirement)

Short-Term Disability:

SSI

SSD (disability)

Alimony

Child Support

Unemployment

Public Assistance

Family/Friends Support

Other

Monthly Household Expenses

Mortgage/Rent

Is mortgage/lease in your name?

Yes

If no, explain

Utilities

Home/Renter’s Insurance

Car Payments

Health Insurance

Cable/Internet/Phone

Medical Bills

Auto insurance

Childcare

Gas

Groceries

Cell Phone(s)

Other (specify)

How did you hear about Dear Diabetes?

Please elaborate on your individual situation of need (tell us your story). Please use additional space and/or include photos if you so desire.

CONSENT FORM

Confidentiality Clause

Dear Diabetes considers this application and its attached information confidential. Dear Diabetes shall not use the confidential information other than for the purposes of its business with the applicant and shall disclose it only to its officers, board members, or government agencies with a specific need to know. Dear Diabetes will not disclose,publish, or otherwise reveal any of the confidential information received from applicant to any other party whatsoever except with the specific prior written authorization of Applicant. By signing below, you give Dear Diabetes authorization to speak with the social work department and/or doctors to verify your situation.

Initials

Date

Publicity Authorization

I authorize Dear Diabetes to publicize information about myself or my family (including a medical condition, whether embodied in photographs, videotapes, recordings, and any other format (collectively, “Information”), for the purposes of promotion, publication, commercial advertising, or any other purpose whatsoever, now or at any time in the future. Participants understand and agree that Dear Diabetes may use any such information: (1) in all manner and media whatsoever, whether now known or hereafter invented, including electronic and print media and the Internet; (2) with or without Participant’s names; (3) without the payment of royalties or other compensation to anyone; and (4) without the need to notify them or to seek further approval before doing so.