Medical Professional Application for Equipment

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.Format: (000) 000-0000.

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

Applicant Height:

Feet and inches

Applicant Weight:

Pounds

Applicant Employment Status (Check all that apply)

Applicant Race

Is or has the applicant had any of the following: (Check all that apply) (for grant reporting purposes only)

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?

If you have insurance, will it cover any of the items you are requesting?

If yes, please contact your insurance provider first. F.R.E.E. is a non-profit of last resort.

In the last 30 days...

Rows	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)

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.

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.Format: (000) 000-0000.

Email

example@example.com

From which FREE location will you be picking up equipment?

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

Other Amount

Additional info/comments: (i.e. additional info needed about the client or situation, inventory number if applicable, etc.)

Name

First NameLast Name

Phone Number of person picking up equipment

Please enter a valid phone number.Format: (000) 000-0000.

MEDICAL PROFESSIONAL Application for Mobility Rehab Equipment

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