Submit an Application Form

Birth Control Program Application

Desert Star Institute for Family Planning, Inc., understands that sometimes people face financial challenges, and we are here to help. We have partnered with Direct Relief, a charitable organization, to provide Liletta® intrauterine devices to qualified patients and we have also secured funding to offset the cost of the Nexplanon® implant.

"*" indicates required fields

Check the box for the device you are requesting. Just check one box.*
Name*
Address*
What is your preferred contact method?*
Our program assistant will contact you to review your application and determine your eligibility.
What is the best time to contact you?
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Are you of Hispanic, Latino, or Spanish origin?*
How would you describe yourself?*
Household Information*
Please provide the number for each column of adults and minors in the first columns and the total in the last column.
Number of Adults in Household
Number o Minor Children/Dependents
Total Number in household
 

Do you have health insurance?

Private health insurance or insured through Employer*
Medicare*
AHCCCS (Medicaid)*
VA (Veterans)*
Uninsured*

Please list your MONTHLY gross household income (Income before taxes or deductions) calculated for all household members Age 19 or older

Pay, Wages, or Salaries
Tips
Unemployment benefits
 
Social Security Benefits
Public Assistance Benefits (TANF)
Disability, workers compensation, or other payment for an injury or illness
 
Retirement or pension benefits
Alimony or child support payments
Insurance or annuity payments to me
 
Interest or dividends from savings accounts or investments or any withdrawals from these accounts
Rental income or other income from a Business
Income from royalties, patents, gambling, or lottery winnings
 

Patient Attestation:

I attest that all the information that I have provided to determine my eligibility for this product donation program is complete and correct to the best of my knowledge. I understand that I cannot request reimbursement for any prescription product received through this program from any government program or third-party insurer. I further agree to notify the clinic of any changes in my income or insurance, or other factors used to determine my eligibility status were I to receive donated product in the future. I authorize the release of my Protected Health Information (PHI) for this patient assistance program or any third parties retained to administer the program and who may audit my PHI for the purpose of verifying my eligibility.
Printed Name*
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