Impact Statement

Due to the FY12 budget cuts to MoKP, I have been affected by:

(Check all that apply)

1. Loss of MoKP's Transportation Assistance

Yes No
     This has lead to:
          Number of missed dialysis appointments
          Number of missed transplant appointments
          Did this result in ER visits? Yes No
          Did this result in any hospital visits? Yes No

2. Loss of MoKP's Insurance Premiums Assistance

Yes No
     This has lead to:
          Loss of my insurance coverage Yes No
          Can't cover rent Yes No
          Can't cover utilities Yes No
          Can't cover food Yes No
          Rely more on family for assistance Yes No

Other: Explain

3. Loss of MoKP's Nutritional Supplement Assistance

Yes No
     This has lead to:
          Hunger Yes No
          Weight loss Yes No
          Slower healing Yes No

Other: Explain

4. Because of the loss of MoKP's assistance I have to rely on:
          Family Yes No
          Friends Yes No
          Church Yes No
          Social service agencies Yes No
          No one is available Yes No

Other: Explain

I want the legislators to know that Missouri Kidney Program is important to my health because:

Personal information (optional)
          Address 1:
          Address 2: