Medical Equipment Application

Medical Equipment Application
The Process

* Initial each step in the process to indicate that you have read and understand.
Initials* Step 1: The patient or their assigned Advocate (if a minor) completes the online application. This initiates the vetting process, whereby eligibility will be determined based on meeting the criteria listed above.
Initials* Step 2: The vetting process takes place. The applicant will receive a phone call from an All Things Possible Medical Fundraising associate to clarify information provided on the application.
Documents and waivers will be emailed to the applicant and are required to be signed and returned to our Administrator before the application process moves ahead.
During this time, you will also be referred to a nonprofit crediting counseling service (at no cost to you) to review the financial information you have provided on the application. This service will also provide financial resources and budgeting recommendations. Once all information is verified, it will be presented to our Medical Review Team, which includes medical and financial professionals, who will examine all the details. The synopsis and recommendations will be presented to our Board of Directors. The Board will vote to determine whether we move forward at that time.
Initials* Step 3: Once the applicant is qualified on paper and approved by the Board of Directors to move ahead, a video interview will be scheduled. The individual in the wheelchair, as well as their caregiver(s), are required to be present. If the applicant cannot speak clearly, their advocate or caregiver will be interviewed, with the applicant in the room.
The video interview will either take place at the home of the applicant or will be recorded via Zoom. The decision as to where and how the video interview is conducted is at the discretion of our All Things Possible videographer.
Initials* Acceptance: The leadership of All Things Possible Medical Fundraising reserves the right to accept or decline the application based on necessity, financial information, urgency, and/or the ability to make a significant difference for the patient, as evidenced by the available information. However, if the applicant’s circumstances change or important new information comes to light after acceptance, All Things Possible reserves the right to reverse or amend its decision.

The applicant will be notified by a phone call from one of our associates once an approval decision has been made. If accepted, the next steps will be detailed within that notification call. If declined, the applicant will receive written notification. The decisions of the Board of Directors for All Things Possible Medical Fundraising are final.
All Things Possible Medical Fundraising currently serves those living in North Carolina and South Carolina. If approved and gifted a van, recipients must transport themselves to Ilderton Conversion Company in Charlotte, NC to pick up their van and drive it home.

IMPORTANT: Before proceeding please note: If you are approved, and when you receive a wheelchair van, you must be able to drive to the Ilderton Conversion Van Dealership in Charlotte, NC to take possession of the vehicle. At that time, paperwork is completed, and you must bring the money for tax, title, and transfer fees, which is payable to Ilderton Conversion Company. That amount is largely based on the price we pay for the vehicle and whether you live in NC or SC. The exact amount due (generally between $1800 and $2200) will be told to you in advance. All Things Possible purchases our vehicles from this dealership only and will not deliver the van to you. You are responsible for making the arrangements to pick up the vehicle in Charlotte, and both the patient and driver/owner of this vehicle must both be present. If that isn’t possible, you can exit the application now.

The All Things Possible Board of Directors determines whose need is funded next based on the availability of funds, the best match of physical limitations to the type of mobility equipment that becomes available, and the urgency of need.

All Things Possible partners with Ilderton Conversion Company whose experts in mobility vans help select the appropriate vehicle based on the specific disability.

Disabled Driver

We require applicants requesting wheelchair vans with hand controls, to have a valid driver's license with the #9 restriction (which requires full hand controls) in their possession prior to completing the application.
Are you requesting a wheelchair van with hand controls?*

NoYes
Do you have a valid driver's license with the #9 restriction?*

NoYes
Once you have a valid driver's license with #9 restrictions you can submit an application.
Have you ever received a wheelchair van from All Things Possible Medical Fundraising in the past?*

NoYes
Occasionally, there may be circumstances that render a previously gifted van from All Things Possible Medical Fundraising (ATP) inoperable. These reasons may include, but are not limited to: an accident resulting in total loss, passage of extended time since last van gift, extenuating circumstances, and more. In such cases, ATP will consider the opportunity to provide another van to a repeat applicant. However, we require additional information from repeat applicants in order to assess each case fairly. Please provide the following details:
Date you received your most recent van from All Things Possible:*
Total number of vans you have received from All Things Possible:*
Provide an explanation as to why your prior van(s) are no longer able to be used.*
Upload any supporting documentation for your response in #3 (insurance records, repair shop quotes, police/accident report, etc.).*

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Upload documentation confirming any payments agreed upon and received from an insurance company or third party.*

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ATP requires that ALL insurance payouts awarded due to the loss of your previously gifted van must be used toward the purchase price of a newly gifted van. Upon the approval of a repeat applicant, ATP will make up the difference between the amount paid by the insurance settlement and the purchase price of the new van selected by our organization.

A repeat applicant is required to go through the full review and reapproval process. In addition to the regular criteria used for determining van eligibility, a repeat applicant may be denied based on the factors resulting in the loss of their prior van(s). These factors include, but are not limited to: being at fault in an accident, owner negligence, noted instances of carelessness, overall disposition of the applicant, etc.

Vans will be awarded based on availability, applicant circumstances, and current applicant pool. First time applicants may be given priority. Van eligibility for returning applicants will be considered on a case-by-case basis by our Medical Committee, Finance Committee, and ultimately the ATP Board of Directors.
By checking below and continuing this application, you are affirming that you live in the area we serve:

I am currently a resident of North Carolina or South Carolina

Required Documents
To complete this form, you will be asked to provide either a photo or scan of the following documents:
- Drivers License
- Proof of Auto Insurance
- Proof of Income ( pay stubs )
You will also be asked to submit a brief (2 minute) video explaining why you need assistance from All things Possible Medical Fundraising.

Please have copies of all your recent bills/payments made and income statements handy as they will be necessary when you speak with the financial counselor.

We understand that it may take some time to assemble these documents and prepare your video. Please use the "Save" button at the bottom of each page to save your progress along the way. In order to do this, you will need to create an account using your email address.

Please take a moment and click "Save" now, to complete this step before proceeding.

Medical Need Information
Medical Diagnosis resulting in need for equipment:*
Date of initial diagnosis:*

MonthDayYear
Date
In detail, please share the history leading up to applicant’s diagnosis, and the age of the applicant when diagnosed.*
In detail, list the applicant’s current limitations and complications associated with this diagnosis.*
What type of mobility equipment are you requesting from All Things Possible?*

Pre-owned Wheelchair VanRepair to Mobility Components of Current Wheelchair Van (Applicant must take vehicle to one of 4 Ilderton Conversion locations for an estimate and repairs. Those locations include: Asheville, High Point, and Charlotte in North Carolina, or Charleston, South Carolina)
* I understand that All Things Possible will only cover the cost of repairs related to mobility components and mechanisms, and not general vehicle maintenance and repairs.*

Yes, I understand this.
Who will be the owner(s) of the wheelchair van?*
Owner/Driver's Full Name
What is the phone number(s) of the owner(s)?*
Please enter a valid phone number.
Is the owner(s) of the wheelchair van employed?*

YesNo
Employer Company Name*
Employer Contact Name*
Employer Contact Phone Number*
Please enter a valid phone number.
Who will be the driver of the wheelchair van?*
Owner/Driver's Full Name
What is the phone number of the driver?*
Please enter a valid phone number.
Is Patient in wheelchair 100% of the time?

YesNo
If "No" above, please explain in detail:

Pre-owned Wheelchair Van Request Information
If requesting a pre-owned wheelchair van:
What type of wheelchair are you now using and needing to transport?

Brand Brand Model Model
Age Age
Manual or Power Other
Do you currently own, or have you ever owned, a wheelchair van?*

YesNo
If you currently own a wheelchair van:

Year Brand Make Model
Model Age
Mileage Other
Why is this van no longer working for you?:
If you do not currently own a wheelchair van, describe in detail how are you transporting the applicant now. Give details such as whose vehicle do you use, how do you get the applicant into the vehicle, where do you stow the wheelchair, what type of vehicle is used, who drives the vehicle, using public transportation & what that involves, etc. *
What locations does the patient/user need to travel to and from, and how often (per week or month)? Examples: Medical/Therapy appointments – 3 times a month, Church – once a week, Work – 5 days a week, etc.*
Do you have a vehicle of any type to use as a trade in?*

YesNo
Vehicle Details:

Year Brand Make Model Model
Mileage Other
Any repairs needed? If YES, please explain in detail. If none, type NO.
What is the approximate amount still owed on this vehicle (if any)?

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

This section is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.
Name of Patient*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I. My Authorization
I authorize the following using or disclosing party: (Primary Doctor and/or Therapist(s) & their Contact Information:

Primary Physician Name:   First Name*   Last Name*
Practice Name:   Practice Name*
Practice Address:.
Street Address*      City*   State*   Zip*
Primary Physician Phone Number*
Please enter a valid phone number.
PT/OT Therapist Name:   First Name   Last Name
Email:
Practice Name:   Practice Name
Practice Address:.
Street Address   Address Line 2   City   State   Zip

To use or disclose health information relating to the following treatment or condition:
PT/OT Therapist Phone Number
Please enter a valid phone number.
Please enter diagnosis or condition being treated
The above party(s) may disclose this health information to the following recipient:

All Things Possible Medical Fundraising or its assigns.
3160 Hwy 21, Suite 103, Box # 57
Fort Mill, SC 29715
704-560-9005 or 803-389-4108

Karen Long: karen.allthingspossible@gmail.com

The purpose of this authorization is: (1) To confirm/verify medical information regarding the necessity of mobility equipment requested. (2) Release All Things Possible Medical Fundraising to publish this information to the public in connection with promoting fundraising.

II. My Rights

Term: This authorization is in perpetuity. I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.

I may receive a copy or photograph of this authorization after I have signed it. A copy of this authorization is as valid as the original.
Signature of Applicant or Advocate, (if applicant is unable to sign or is underage).*

Clear
Name of person signing:*
Date*

MonthDayYear
Date
If the person is a minor or unable to sign, please complete the following:
Person is a minor        years of age

Person is unable to sign because of this physical disability/diagnosis:
Authority of representative to sign on behalf of the patient:
Parent Legal Guardian Court Order Other
Signature of Legal Guardian / Representative: (electronic signature is valid)

Clear
Name of person signing:
Date

MonthDayYear
Date

AGREEMENTS

Please initial each statement to indicate that you agree with the statement
Initials* I understand and agree that the criteria to be considered a viable candidate for receiving any mobility equipment or vehicle from All Things Possible Medical Fundraising includes this application completed honestly, and in its entirety, along with any additional documentation requested by All Things Possible Medical Fundraising representatives. The application and financial information submission begins the applicant vetting process.
Initials* I understand and agree that any medical equipment provided by All Things Possible Medical Fundraising must be prescribed/recommended by a treating medical professional and must be deemed “not a covered item” by your commercial insurance provider, Medicare and/or Medicaid. We reserve the right to review the recipient’s medical benefits, confirming coverage or non-coverage with the provider.
*No initial required for wheelchair van application. (Section to follow for uploading written recommendation from the medical professional and written denial of coverage from your insurance provider).
Initials* You may be contacted by an All Things Possible representative by phone or email for additional clarification or information in the weeks following the submission of the application. Please reply in a timely manner to keep the process on track.
Initials* I understand and agree that wheelchair vans will be allocated to families who meet all the criteria to include a significant number of necessary medical and/or therapy visits as determined by the medical provider(s).
Initials* I understand and agree that a proper match will occur when there is a clearly demonstrated need/urgency, funds are available to purchase a wheelchair van, and the appropriate van for the family is available through our contacts within the acceptable price range. (For example, some wheelchairs will fit better in a rear load versus a side load van, a large family will require a larger vehicle than a family of 2 or 3, headroom clearance is a factor for taller wheelchair users, etc.) If the family has funds saved to contribute toward the vehicle, this may expedite the process. If the family has a vehicle to use as a trade-in, this too may expedite the process, depending on the value of the trade.
Initials* I understand and agree that the final decision on which applicants are approved to proceed are made by the Board of Directors for All Things Possible Medical Fundraising. You will receive either phone call or letter in writing with the determination of the Board, which meets quarterly. All Things Possible Medical Fundraising has no idea when or how much will be received in donations; therefore, we offer no guarantees in writing or implied as to approximately when you might receive a wheelchair van. It could be weeks, months, or years.
Initials* I understand and agree that I must show the ability to pay for the average monthly cost of ownership and maintenance of a wheelchair van including gas, periodic maintenance and repairs plus the additional cost for insurance (which is higher than a standard vehicle). This is to ensure that maintaining the wheelchair van is not a financial burden on the family. Any and all repairs to equipment provided by All Things Possible Medical Fundraising are the sole responsibility of the recipient.
Initials*I understand and agree that All Things Possible Medical Fundraising never takes title to the vehicles we gift to families in need. The ownership transfers from the seller/dealership directly to the recipient (driver). Therefore, the receiving family is responsible for paying all title, taxes and transfer fees legally required by purchasers of vehicles. This amount is generally between $1800 and $2200, depending on the value of the vehicle. These funds need to be readily available to you (in checking or savings account) prior to submitting this application. The actual cost of the vehicle will be paid for through donations received by All Things Possible Medical Fundraising, while all future costs are the responsibility of the recipient family. The wheelchair owner will be required to pay Personal Property Taxes on the wheelchair van within 30-90 days of ownership and transfer of title. This yearly tax varies based on the state and county you live in and could range $600 and up. This tax is the sole responsibility of the owner.
Do you have the funds for the title, taxes, and fees readily available?*

YesNo
Initials*All Things Possible will not deliver the van to you. You are responsible for making arrangements for the wheelchair user to be in Charlotte for the presentation of the van, paying the fees required (which will be told to you in advance), and completing the necessary paperwork to take ownership. The local Charlotte, NC media will often be onsite to record the presentation, along with our own videographer.

All Things Possible purchases our vehicles from the Ilderton Conversion Company. This is a wheelchair van/mobility vehicle specific dealership in Charlotte, NC. Ilderton Conversion Company is family owned and has been in business since 1972. Their mobility consultants and service technicians are factory trained and certified. Ilderton Conversion Company is a member of the National Mobility Equipment Dealers Association (NMEDA) and an active participant in NMEDA's Quality Assurance Program (QAP).

The address is: Ilderton Conversion Company. 1424 Archdale, Charlotte, NC 28210. www.ildertonvans.com
Initials* I am willing to work with a financial counselor to do a review of my current financial situation. (This will be at no cost to you)
If you are not approved this time but then your circumstances change and you would like to reapply, you are encouraged to do so.

FINANCIAL NEED INFORMATION
In detail, why is mobility equipment financially unattainable for you and your family?*
Are you currently receiving financial assistance?*

MedicaidMedicareNone
FINANCIAL SECTION
Savings Account(s) Balance*
MONTHLY Income and Sources

Document all monthly income sources and amounts for the household. Examples of income include, but are not limited to: Social Security payments, pension, work income, alimony, child support, etc.

*Use only whole dollars and no cents. Do not insert: periods, $ signs, + signs, or dashes. If you only know the annual amount, fill in a monthly average (annual $ divided by 12 = monthly average)

Below list the entire family's NET household income and expenses.

Total Monthly Income
Please Upload One Month's Worth of Paystubs. If you are receiving social security payment(s) and/or SSI, upload the social security documents showing monthly payment(s) to you.*

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Monthly Expenses

*Use only whole dollars and no cents. Do not insert: periods, $ signs, + signs, or dashes. If you only know the annual amount, fill in a monthly average (annual $ divided by 12 = monthly average)

**Each "Monthly Amount" field is required. If the expense type doesn't apply to your situation, just enter "0" and move on.

Clothing*

Monthly Amount Notes

Clothing

Total Monthly Expenses
Net Monthly Income ( Total Income Minus Total Expenses )
Wheelchair Information

This information will help us to select the appropriate van when the time comes.
What brand name is on the wheelchair that needs to go into the van?
Upload 2-3 pictures of the patient sitting in the wheelchair in full view. Picture must include above the top of the head to below the wheels. Pictures must be clear.*

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Please list any organizations that have already completed fundraisers for this patient. Include the name of the organization(s), date(s) of events, dollars raised and the contact information for the organization(s). Please include any Group-Fund-Me type fundraisers in progress or completed. If none, type "None".*
AGREEMENT (patient or primary contact/Guardian to read and initial)

All Things Possible Medical Fundraising makes no promises or guarantees that you will be selected as a recipient. You may be contacted for clarification relating to your financial inability to obtain a wheelchair van or other mobility equipment on your own.

It is important that you respond to these calls from our vetting team quickly and supply any requested documentation within a timely manner. If after 3 contacts (using the contact information you provide), our representative is unable to get a response, your application will be rejected. You can resubmit after 6 months.
Please Upload a short Video (maximum 2 minutes) expressing why you need assistance from All Things Possible Medical Fundraising*

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Upload the front & back of the driver’s license for the person who will own and drive the wheelchair van. Driver’s license must not be expired. Pictures must be clear and legible.*

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Upload front and back of current insurance card for the person who will own & drive the wheelchair van. Insurance cannot be expired. Pictures must be clear and legible.*

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Signature of Patient or Legal Guardian:*

Clear
Date*

MonthDayYear
Date
By submitting this form, you assure us that all of the above information is accurate and that you understand and agree to the process outlined.
Should be Empty:

	MONTHLY Amount	Vehicle Year / Make / Model
- Car #1 - Loan Payment
- Car #1 - Vehicle Property Tax/Registration Fee/Inspection Fee
- Car #2 - Loan Payment
- Car #2 - Vehicle Property Tax/Registration Fee/Inspection Fee
- Car #3 - Loan Payment
- Car #3 - Vehicle Property Tax/Registration Fee/Inspection Fee
- Gas and oil - (total all vehicles)
- Repairs and tires - (total all vehicles)
- Auto Insurance - (total all vehicles)

	Monthly Amount	Notes
- Mortgage/rent
- Taxes
- Repairs
- Home/Rent Insurance

	Monthly Amount	Notes
- Electric
- Gas
- Water
- Trash

	Monthly Amount	Balance Owed
- Credit Card Debt
- Student Loans
- Personal Loans

	Monthly Amount	Notes
- Phone / Mobile
- Internet
- Cable / Satellite

	Monthly Amount	Notes
- Life Insurance
- Health Insurance
- Disability Insurance
- Childcare / Adultcare
- Entertainment
- Vacation
- Medications/Glasses
- Dentist/Doctor
- School Tuition
- Child Support/Alimony payments
- Pet Care
- Nails/Hair
- Beauty Supplies
- Church Offerings
- Holiday & Birthday Gifts

	Income Source	MONTHLY Amount
1
2
3
4
5
6
7
8
9
10

	Monthly Amount	Notes
- Groceries
- Eating out

Medical Equipment Application

The Process

Disabled Driver

Required Documents

Basic Information

Medical Need Information

Pre-owned Wheelchair Van Request Information

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

I. My Authorization

II. My Rights

If the person is a minor or unable to sign, please complete the following:

AGREEMENTS

FINANCIAL NEED INFORMATION

AGREEMENT (patient or primary contact/Guardian to read and initial)