Application for Equipment - FREE Foundation

Thank you for connecting with F.R.E.E. We provide services to low-income adults in VIRIGINIA. If you are NOT in VIRGINIA, please check out www.passitoncenter.org. Because we reuse durable medical equipment donated by the community, equipment availability is based on items donated to us.

A note from a medical professional is REQUIRED for ALL equipment being requested. Your application can NOT be processed until all information is completed.

F.R.E.E. does NOT provide or take respiratory devices, nebulizers, oxygen, CPAP, or hospital beds.

If approved (based on income and medical need), all items are gifted to you and are yours. You assume all responsibility for the equipment including its proper maintainance and use.

If you are you completing this application on behalf of someone else, please write your name or company name below and phone number/email: *

Phone Number *

Please enter a valid phone number.

Email

example@example.com

Information about Individual Seeking Equipment

Applicant Name *

First Name Last Name

Phone *

Area code and phone number.

Address *

Street Address

Street Address Line 2

City State

Zip Code

County *

Age *

Date of Birth *

Month Day Year

Gender *

Male Female

Height: *

Feet and inches

Weight: *

Pounds

Employment Status (Check all that apply) *

Retired Employed Unemployed Disabled Student

Race *

African American Asian American Hispanic American Caucasian Other

Applicant's Health Information and Equipment Needs

Please describe your current medical problems and indicate when they began. *

Referring Doctor or Therapist's Name *

First Name Last Name

Title of referring medical professional *

Doctor, Physical Therapist, Occupational Therapist, Social Worker, Nurse, EMS

Medical Professional's Company *

Medical Professional's Phone number *

Area code and phone number

What type of equipment do you need? *

What type of equipment do you currently have? *

Household MONTHLY income *

What are your current MONTHLY uncovered medical expenses (out of pocket)? *

How many dependents live at the residence (including applicant)? *

Which of the following do you currently have? *

Health insurance Medicare Medicaid None

In the last 30 days... *

Response

How many times have you fallen?

How many times have you gone to the ER?

How many times have you gone to the hospital?

Without this equipment, will you have to change your residence to any of the following? (Check all that apply) *

Family Member Assisted Living Nursing Home none of the above

Required Documentation

Please upload a completed Letter of Medical Necessity. Applications cannot be processed until this form is provided. The form may also be faxed or emailed to a F.R.E.E. program nearest you. *

Note from medical professional or prescription (document or photo).

Which FREE location will be picking up equipment? *

Roanoke (1489 East Main Street, Salem, VA 24153) Richmond (6301 Midlothian Turnpike, Richmond, VA 23225) South Hampton Roads (Mailing: P.O. Box 66207, Virginia Beach, VA 23466) Lynchburg (Tate Springs Medical Center, 1900 Tate Springs Rd., Suite 21, Lynchburg, VA 24501) Northern Shenandoah Valley (333 West Cork Street, Suite 40, Winchester VA, 22601) Williamsburg (701 Sentara Circle, Williamsburg, VA 23188)

Our services are charity-based. If possible, please consider making a donation for continuation of our services.

$1.00 $5.00 $10.00 Other Amount

The undersigned certifies that all information provided within this application is accurate to the best of your knowledge and is subject to verification. I, the customer, acknowledge that any equipment or information about the equipment given to me is a gift to me by the foundation. I accept all responsibilities for the equipment. I waiver any right to hold the Foundation for Rehabilitation Equipment & Endowment and any of its representatives responsible for any injury obtained using this equipment. As well, I assume the responsibility of the maintenance and upkeep for the item(s).

Please enter your name to acknowledge that you have read the Terms of Service. *

First Name Last Name

Application for Mobility Rehab Equipment