• 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 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.  

    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

  •  - -Pick a Date
  • Applicant's Health Information and Equipment Needs

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  • 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. 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).

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

  • Should be Empty: