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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 Card
Chronic Pain Management
Other Prescription Management
Mental 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 Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Date of birth
*
-
Month
-
Day
Year
Date
converted Date of birth
-
Year
-
Month
Day
Date
Age
*
Zip Code
*
My main healthcare need is
*
Physical Illness or Injury
Chronic pain
Mental Health
Other
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 Card
Yes, I have an active card that I need to renew
Yes, I had a card before but it is expired
I'm not sure
I have no interest in using Medical Cannabis
When does your current Medical Cannabis Card expire?
-
Month
-
Day
Year
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 taxes
I am not a dependent on anyone's taxes, and I do not have any spouses or dependents
I have a spouse or domestic partner and no dependents
My spouse and I have one or more dependents
I 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
Please report you & your household's annual income from each of the four sources listed in the table below. You must fill in each column for each person in your household, even if all answers are 0.
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
Please report you & your household's annual income from each of the four sources listed in the table below. You must fill in each column for each person in your household, even if all answers are 0.
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
Please report your annual income from each of the four sources listed in the table below.
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
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
Cancel
of
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
Cancel
of
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)
Submit Application
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