Medical Professional Application for Equipment

MEDICAL PROFESSIONAL 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 VIRGINIA. 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.

Your medical note is NOW INCLUDED HERE. NO need to attach any forms. A medical professional, who can complete this form is defined as physician, physician assistant, nurse, social worker, occupational therapist/assistant, physical therapist/assistant, case managers, and EMT/community paramedicine provider.

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 your client and are theirs. They assume all responsibility for the equipment including its proper maintainance and use.
Information about Individual Seeking Equipment
Applicant Name*

First NameLast Name
Applicant Phone*
Area code and phone number.
Applicant Email (if available)
example@example.com
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
Is or has the applicant had 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 these
Applicant's Health Information and Equipment Needs
Please describe your current medical DIAGNOSIS/problems and indicate when they began.*
What type of equipment do you need?*
IF providing equipment from a medical closet, please provide inventory number (if applicable.)
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

This question now serves as the letter of medical necessity.

I certify that the above requested equipment is necessary for the client's safe mobility and activities of daily living.

This is your medical letter of necessity. NO need to attach any forms.

A medical professional, who can complete this form, is defined as physician, physician assistant, nurse, social worker, occupational therapist/assistant, physical therapist/assistant, case managers, and EMT/community paramedicine provider.

The undersigned certifies that all information provided within this application is accurate to the best of your knowledge and is subject to verification.
Terms of service waiver: I have shared the following waiver of responsibility information with my client: My client and I acknowledge that any equipment or information about the equipment given to me is a gift to me from the foundation. I accept all responsibility for the equipment. I waive any right to hold the Foundation for Rehabilitation Equipment & Endowment and any of its representatives responsible for any injury obtained using this equipment. Also, I assume the responsibility of the maintenance and upkeep for the item(s) and will use it correctly.*

YES
Type your name here as your signature to certify the equipment is medical necessary and the applicant understands the Terms of Service:*

First NameLast Name
Title of referring medical professional *
Doctor, Physical Therapist, Occupational Therapist, Social Worker, Nurse, EMS
Medical Professional's Company*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
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, 1901 Thomason Drive, Suite C, 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
Additional info/comments: (i.e. additional info needed about the client or situation, inventory number if applicable, etc.)
Who do we call to pick up the equipment once ready?
Name

First NameLast Name
Should be Empty:

MEDICAL PROFESSIONAL Application for Mobility Rehab Equipment

Who do we call to pick up the equipment once ready?