Assistance

Thank you for contacting DEAR Diabetes.

Please allow ten days to review your request. We may follow up with additional questions.

We are a volunteer organization with limited funding; however, we understand the financial burden of managing diabetes and will make every attempt to provide some level of financial assistance.

Please note, our focus is in Nebraska and primarily Omaha, Nebraska.

If you are in immediate need of assistance, please contact 211

PATIENT INFORMATION

Please complete all sections of the questionnaire.

First Name

Middle Name

Last Name

Email

Cell Phone

Work Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Date of birth. Enter as MM/DD/YY

Gender

Male

Female

Non Binary

MEDICAL INFORMATION

Please enter the Month and year diagnosed with diabetes

Please indicate what type of diabetes you have

Last A1C Reading

Date last A1C was tested

HEALTHCARE PROFESSIONAL

Who do you see to manage your diabetes?

Healthcare Professional Name

Hospital/Clinic

Address

City

State

Zip Code

Phone

Please provide a letter from your medical professional stating your diagnosis and any other medical conditions which may be impacting your quality of life or contributing to your ability to work. The letter must include your last A1C reading and date.

Choose File

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

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

$

Are you currently:

Employed

Retired

Student

Other

Other - please explain

Number of immediate family members in the household including yourself

Please list family members living with you. 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

$

Support from Family/Friends

$

Other (specify)

$

Monthly Household Expenses

In order for DEAR Diabetes to provide rent or utility assistance, the obligations must be in your name. A copy of the lease agreement or mortgage statement must be attached.

For rental assistance, the assistance will be paid to the owner of the property on record with the Assessor's site.

Mortgage/Rent

$

OPPD

$

Home/Renter’s Insurance

$

Car Payments

$

Health Insurance

$

Cable/Internet/Phone

$

Medical Bills

$

Auto insurance

$

Childcare

$

MUD

$

Groceries

$

Cell Phone(s)

$

Other (specify)

$

Please upload copies of the bills you wish to have paid The account must be in your name and the address must match the address you provided.

Choose File

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

How did you hear about Dear Diabetes?

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.