• a participating health care provider
• an eligible and qualified recipient

Health Care Providers

To participate, a health care provider must enroll in the Insulin Pumpers Foundation Pump Assistance Program. A participating health care provider must provide ALL training and support for a recipient of an insulin pump from the Pump Assistance Program. Insulin Pumpers Foundation does not provide any support or training for insulin pump recipients. If you are a health care provider interested in participating in the program, please contact us and fill out and return a copy of the:

• Physician Participation Agreement

Patients

The Insulin Pumpers Foundation Pump Assistance Program was conceived to assist patients with financial constraints in obtaining insulin pump therapy.

Eligibility Criteria for Recipients (subject to availability of donated insulin pumps).

• potential Recipients must be able to purchase their own insulin and pump supplies
• a participating health care provider must deem insulin pump therapy a medical necessity for a potential Recipient (Note: the potential Recipient's health care provider must submit a Pump Assistance Program Patient Referral Form on behalf of the program applicant.)
• low income
• uninsured or under-insured (if you are insured and your insurance company will not pay for an insulin pump, please submit a written explanation and a copy of your contract of insurance along with your application -- contract copy not required for Medicare/Medicaid)

Application Process

• contact your health care provider and determine if they are an Insulin Pumpers Foundation Pump Assistance Program participant. If they are not, ask them to contact Insulin Pumpers Foundation to enroll.
• complete the Application and Financial Disclosure Form
• complete an IRS Tax Information Authorization Form
• complete an Authorization to Release Medical Information
• complete an Insulin Pumpers Foundation Patient Agreement

Fees

• $25.00 - non-refundable application fee
• When you are notified that your application is accepted, a $196 processing fee is due and payable to Insulin Pumpers Foundation before we may contact your health care provider and complete the final steps of the process.

Where to submit an application

When the necessary forms and their attachments are completed, submit them along with the application fee to:

Insulin Pumpers Foundation
558 Valley Way
Milpitas, CA 95035-4106

Insulin Pumpers Foundation will review your application upon receipt and will contact you within three weeks to let you know if you've been accepted into the program.