To apply for participation in the Utah Insulin Savings Program, please complete and submit all of the information below. Once your information has been reviewed and verified, you will receive a secure email with your ID card and information regarding how to use the program. If you have questions, please call (801) 366-7551.
I hereby certify under penalty of perjury that I
have read and understand the and I am eligible for the Utah Insulin Savings
Program. I further agree to abide by any instructions and comply with any laws or rules enacted to
receive the discounted rates for insulin. I understand that I will be liable for any discounts received
for which I was not eligible.