Pumps for Purpose Scholarship Application
Adrenal Alternatives Foundation sponsors adrenal patients desiring to start the cortisol pumping method to manage their adrenal disease with discounted pumps and supplies alongside our affiliate, CR3 organization.

Requirements-
1- You must have been diagnosed with an adrenal disease via documented medical testing by a licensed medical doctor or nurse practitioner.
2- You must have a licensed clinician willing to manage your care on the adrenal pump before receiving supplies.
3- You must sign a liability form that the foundation does not provide medical care or advice and is not liable for any healthcare choices.

Adrenal Alternatives Foundation is a 501c3 patient advocacy organization which is HIPPA compliant. The information you provide is confidential will only be used to process your application internally through Adrenal Alternatives Foundation and CR3 Diabetes Association.
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Email *
What form of adrenal disease have you been diagnosed with?
What is the name, practice and phone number of the clinician managing your care? *
Are you currently on the pump?
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Would you like to be provided with more education on the cortisol pumping method?
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Would you like for Adrenal Alternatives to reach out to your clinician in regards to education from our clinical team?
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Please provide your current health insurance information. If you do not have insurance, please skip this section by writing n/a in the form below.
What type of supplies do you need assistance with? *
Required
Contact info
Your name *
Phone number *
E-mail *
Preferred contact method *
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Address *
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