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Uplift Application

UTTHC Uplift Application

Financial need shouldn’t be a barrier to better healthcare. With our Uplift community support program️, KindlyMD brings the right kind of care to those in need who earn less than 150% of the Federal Poverty Level. This form will help determine if you qualify for Uplift assistance. This information is private and not shared. If you need help, please call us at (801) 851-5554.
Waitlist in progress

Please note: Uplift is working with a growing waitlist of qualified applicants in need. We will most likely be able to serve you about 3 months from the day you apply, but we will be in touch soon either way!
Which of the following services are you seeking assistance for? (select all that apply)*

Medical Cannabis CardChronic Pain ManagementOther Prescription ManagementMental Health Therapy

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Great! KindlyMD can help with that. Let's start with some information about you, or the patient you're filling this out for.
Date / Time
Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Date of birth*

MonthDayYear
Date
converted Date of birth

YearMonthDay
Date
Age*
Zip Code*
My main healthcare need is*

Physical Illness or InjuryChronic painMental HealthOther
Tell us a little about it*
Are you a legal Utah resident?*
Do you currently have a Utah Medical Cannabis Card, or have you had one before?*

No, this would be my first Utah Medical Cannabis CardYes, I have an active card that I need to renewYes, I had a card before but it is expiredI'm not sureI have no interest in using Medical Cannabis
When does your current Medical Cannabis Card expire?

MonthDayYear
Date

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Thanks for that background info! We look forward to helping you feel better soon. Next, we'll get some financial information from you to determine what kind of Uplift support we can offer you. You may qualify for 75% assistance by supplying proof of active Medicaid coverage, or you may provide proof of household income to determine whether you qualify for 75% or 100% assistance. Your proof of income may be your annual tax form 1040 OR your recent pay stubs or income receipts.
Would you like to use your Medicaid status or income documentation to apply for Uplift assistance?*

Medicaid status (qualifies for 75% discount)Proof of income (may qualify for 75% or 100% discount depending on income)Other (unlikely to qualify for discount)

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Which of these best describes you?

Someone else claims me as a dependent on their taxesI am not a dependent on anyone's taxes, and I do not have any spouses or dependentsI have a spouse or domestic partner and no dependentsMy spouse and I have one or more dependentsI have one or more dependents, and I do not have a spouse
Including you, how many people are considered in your household/family?*
You + other household members

Net household income*
Will auto-calculate from the worksheet above
Upload your income records here. Upload EITHER your U.S. tax return (form 1040) from the most recent year OR your two most recent pay stubs or other income receipts.

Browse Files
This will only be used to verify eligibility for Uplift Cancelof
Upload your HOUSEHOLD's income records here. If your household members are accounted for on your 1040, you do not need to include anything else.

Browse Files
This will only be used to verify eligibility for Uplift Cancelof
Briefly explain the documents that you uploaded.*
Enter your Medicaid insurance member ID number
OR enter your Social Security Number.
This will only be used to verify your Medicaid status with the Department of Health.
What else would you like us to know about your application?
Lissa Reed SF User ID (Owner)
Should be Empty:

	Gross salary, wages, and tips	Income from business or self-employment	Unemployment compensation, workers’ compensation, social security, SSI, public assistance, veterans’ payments, survivors benefits, pension or retirement income	Interest, investments, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other taxable income
Your income

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5097 S 900 E
Suite 100
Murray, UT 84117

This information is not advice, medical or otherwise.
Please see your medical provider for direct medical advice.

	Gross salary, wages, and tips	Income from business or self-employment	Unemployment compensation, workers’ compensation, social security, SSI, public assistance, veterans’ payments, survivors benefits, pension or retirement income	Interest, investments, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other taxable income
You
Your spouse
Dependent #1
Dependent #2
Dependent #3
Dependent #4
Dependent #5
Dependent #6
Dependent #7

	Gross salary, wages, and tips	Income from business or self-employment	Unemployment compensation, workers’ compensation, social security, SSI, public assistance, veterans’ payments, survivors benefits, pension or retirement income	Interest, investments, dividends, rents, royalties, income from estates, trusts, educational assistance, alimony, child support, assistance from outside the household, and other taxable income
You
Head of household (claims you as dependent)
Household member #3
Household member #4
Household member #5
Household member #6
Household member #7
Household member #8
Household member #9