Application for Equipment - FREE Foundation

Application for Mobility Rehab Equipment

Foundation for Rehabilitation Equipment & Endowment
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:*
Advocate's phone number*
Please enter a valid phone number.
Advocate's Email
example@example.com
Information about Individual Seeking Equipment
Applicant Name*

First NameLast Name
Applicant Phone*
Area code and phone number.
Applicant Address*

Street Address

Street Address Line 2

CityState

Zip Code
Applicant County*
Applicant Age*
Applicant Date of Birth*

MonthDayYear
Applicant Gender*

MaleFemale
Applicant Height:*
Feet and inches
Applicant Weight:*
Pounds
Applicant Employment Status (Check all that apply)*

RetiredEmployedUnemployedDisabledStudent
Applicant Race*

African AmericanAsian AmericanHispanic AmericanCaucasianOther
Have you experienced or are you any of the following: (Check all that apply) (for grant reporting purposes only)

VeteranSpinal Cord InjuredTraumatic Brain InjuredDepartment for Aging and Rehab Services clientNone of the above
Applicant's Health Information and Equipment Needs
Please describe your current medical problems (diagnosis) and indicate when they began.*
Referring Doctor or Therapist's Name*

First NameLast 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 insuranceMedicareMedicaidNone

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 MemberAssisted LivingNursing Homenone 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).
Cancelof
From which FREE location will you 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)Harrisonburg (2000 Beery Road, Harrisonburg, VA 22801)
Our services are charity-based. If possible, please consider making a donation for continuation of our services.

$1.00$5.00$10.00Other 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 NameLast Name
Any additional information you would like us to know?
Should be Empty:

Application for Mobility Rehab Equipment