Application for Assistance

Marlene’s Kaleidoscope: Providing Assistance for Eligible Individuals and Families Living with Lupus
Marlene’s Kaleidoscope (MK4LUPUS) is dedicated to providing financial assistance to eligible individuals and families living with Lupus. We understand that the financial burden of living with a chronic illness can be overwhelming, so we offer reduced payment or free care to those who demonstrate financial need.

You may be eligible for financial assistance if you meet the following criteria:

Limited or no health insurance

Do not qualify for government assistance (e.g. Medicare or Medicaid)

Can demonstrate financial need

Reside in the Greater Kansas City area, including Missouri and Kansas
Provide Marlene’s Kaleidoscope (MKLUPUS) with necessary information about your household finances

To apply for financial assistance, please follow these steps:
Fill out the Marlene’s Kaleidoscope (MK4LUPUS) Financial Assistance Application form and submit the following required documents:
Proof of income
Bill copies
Reason for financial assistance
Documentation confirming a diagnosis of Systemic lupus erythematosus, Cutaneous lupus erythematosus, or Drug-induced lupus erythematosus

Determine the level of assistance available to you based on your income and family size using our sliding scale based on federal guidelines. We will review your application and contact you to let you know if you are eligible for financial assistance.

Please note that due to limited staff and funding resources, it may take up to two weeks or more before we can review your application for services. All applications must be fully completed, and incomplete applications will be denied.

Marlene’s Kaleidoscope, we are committed to helping you access other programs and services through collaborative partnerships and referrals. Essential Medical Need Assistance is paid directly to the service provider. If you have any questions about our application process or eligibility requirements, please do not hesitate to contact us at Info@mk4lupus.org. Applicants may request funds once per calendar year.
Do you have Lupus or someone in your household?*

YesNo
If it is not you, then who has Lupus? Their name and age.*
What is the Lupus or Lupus Relate diseases diagnosis?*

SLECutaneous(Skin)NeonatalLupus NephritisSclerodermaSarcoidosisSjogren'sSyndrome -
What are you needing assistance for?*

Electric BillWater BillGas BillGroceriesDoctor VisitMedicationother
Name*

First NameLast Name
Email*
example@example.com
Street Address*
City*
State / Province*
Postal / Zip Code*
Phone Number*

Area CodePhone Number
Date of Birth*
Marital Status*
Gender*

FemaleMaleNon-BinaryOtherPrefer not to say
Ethnicity*
Yearly Income*
Employment Status*

Full TimePart TimeUnemployedRetiredOther
Physician name and phone number.*
Household Information
List all additional members of your household and their names and ages. If not applicable, put N/A.*
Housing Information
Do you own or rent?*

HouseApartmentMobileOther
Insurance Information
Is anyone in you household Disabled?*

YesNoOther
Account Information

Please provide the account information you need help with. You may include up to two accounts.
Account Holder Name*
If applicable, why is the bill not in your name?
1. Company Name
Account Number
2. Company Name
Account Number
Emergency Type

What type(s) of emergency are you experiencing?
Company Type*

My services is currently shut off.I received a disconnectedI have a past due billEviction
Please upload all needed documents

Cancelof
Please note that submitting a request for financial assistance to Marlene's Kaleidoscope (MK4LUPUS) does not guarantee approval of your application. Our team will review each form upon receipt, and only a limited number of requests will be approved based on available funds. We will only contact you if your request is approved or if we require additional information.

If you have yet to receive a response from us within ten days, Please don’t hesitate to email us at info@mk4lupus and add a Financial Assistance Request in the subject line. By submitting this form, you certify that all the information provided is accurate to the best of your knowledge.

If you need to mail the form please send the completed form to Marlene's Kaleidoscope (MK4LUPUS) Financial Assistance PO BOX 14425, Kansas City, MO 64152, or email it to: llipprand@mk4lupus.org.
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Marlene’s Kaleidoscope: Providing Assistance for Eligible Individuals and Families Living with Lupus

Household Information

Housing Information

Insurance Information

Account Information

Emergency Type