Maurer-Heinsen Home Access Program

Maurer-Heinsen Home Access Program

The Maurer-Heinsen Home Access Program is a compassionate and practical initiative dedicated to enhancing the lives of individuals living with Amyotrophic Lateral Sclerosis (ALS). The program recognizes the importance of accessibility for those with mobility challenges and covers a significant portion of the cost associated with the installation of temporary modular ramps to ensure that people living with ALS can easily navigate in and out of their homes.

To qualify for this program a person must have a diagnosis of ALS/PLS/PMA and no other resources that will cover needed items (e.g. County Assistance, VA, long-term care policy).

If you participate in a county assistance program, please contact your county case manager for information on home modifications.

If you are a veteran, please contact your benefits administrator for information on home modifications.

If you have a Long Term Care Policy, please check to see if it helps to cover the cost of a ramp and let us know when we reach out to you.
Eligibility

Please answer the following questions to confirm your eligibility for this program.
Who is filling out this form?*

I am a person with ALSI am assisting a person with ALS or submitting on their behalf.
Is the person with ALS registered with The ALS Association in one of the following states?*

IowaMinnesotaNorth DakotaSouth DakotaWisconsinNo
Will the ramp be installed in one of the following states?*

IowaMinnesotaNorth DakotaSouth DakotaWisconsinNo
Is the person with ALS a U.S. Veteran?*

YesNo
Thank you for your application.

Thank you for your interest in the Maurer Heinsen Home Access Program. Only persons registered with The ALS Association are eligible for this program.
Thank you for your application.

Thank you for your interest in the Maurer Heinsen Home Access Program. Only persons residing in Iowa, Minnesota, North Dakota, South Dakota or Wisconsin are eligible for this progam
Thank you for your application.

Thank you for your interest in the Maurer Heinsen Home Access Program. A member of our team will reach out to you to discuss your eligibility and discuss next steps.
Thank you for your application.

Thank you for your interest in the Maurer Heinsen Home Access Program. If you are a veteran, please contact your benefits administrator for information on home modifications.
Thank you for your application.

Unfortunately eligibility requirements for our program have not been met at this time.

To qualify for this program a person must have a diagnosis of ALS/PLS/PMA and no other resources that will cover needed items (e.g. County Assistance, VA, long-term care policy).

This program only extends to persons with an ALS diagnosis.

Only persons registered with The ALS Association are eligible for this program.

Only persons residing in Iowa, Minnesota, North Dakota, South Dakota or Wisconsin are eligible for this progam.

If you participate in a county assistance program, please contact your county case manager for information on home modifications.

Thank you for your interest in the Maurer Heinsen Home Access Program, a member of our team will reach out to you to discuss your eligibility and discuss next steps.

If you are a veteran, please contact your benefits administrator for information on home modifications.
PERSON LIVING WITH ALS INFORMATION

Please tell us whom we are serving.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date of ALS Diagnosis*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What is your preferred method of communicating with us?*

Email MeCall Me
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County where the ramp is needed*
ALS Physician*
ALS Clinic Name
Does the person with ALS own their home?*

YesNo
Because you do not own your home, we will need the landlord to approve this home modification.

Please download this form, fill in the information and ask the landlord to sign and date.

Once complete, the form can be emailed to HomeAccessNCT@als.org.
Is the home part of a Home Owners Association?*

YesNo
Because you are a member of a Home Owners Association, we will need the HOA to approve this home modification.

Please download this form, fill in the information and ask an approved HOA representative to sign and date.

Once complete, the form can be emailed to HomeAccessNCT@als.org.
Is the person with ALS enrolled in a county assistance program that helps with home modification?*

YesNo
YOUR INFORMATION

Please share your contact information with us in the event that we have any questions.
What is your name?*

First NameLast Name
What is your email address?*
example@example.com
What is your phone number?*
Please enter a valid phone number.
What is your relationship to person living with ALS?*
Acknowledgement

By typing my name and dating below I hereby authorize The ALS Association to release the above information to Next Day Access, a designated ALS Association partner, to provide ramp services for the Ramp Program.

I understand that fees are negotiated on my behalf and I will be able to accept or decline these fees.

I also understand that this is a cost-share program, meaning there will be some out-of-pocket expenses on my part and that my purchased items will be returned to the program when no longer in use.
Type your name as your signature*
Today's Date*

MonthDayYear
Should be Empty:

Eligibility

Thank you for your application.

Thank you for your application.

Thank you for your application.

Thank you for your application.

Thank you for your application.

PERSON LIVING WITH ALS INFORMATION

YOUR INFORMATION

Acknowledgement