HEALTHCARE LENDING AGREEMENT

STLHELP HOME MEDICAL EQUIPMENT

HEALTHCARE LENDING AGREEMENT
This form is for use by healthcare professionals, case managers, social workers or professional caregivers only.

All HME recipients (clients) or their representative are required to electronically sign the lending agreement, releasing STLHELP and you from liability.

Your patient or their representative will need to complete the "release form" section of this request. Then, should STLHELP have the item, it will be ready for pick up with no further paperwork.

STLHELP is honored to serve you and those you seek to help.
Patient's Name*

First NameLast Name
Patient's First Name*
Recipient First Name
Patient's Last Name*
Recipient Last Name
Patient's zip code*
Patient's zip code
Patient's County/City*
If the item is available, what is your preferred pickup location:*

High Ridge (St. Martin United Church of Christ): Tues and Th: 10 am to 2 pmJefferson County HELP Warehouse (Crystal City): Wed and Sat: 9 am to 1:30 pmLemay (Aging Head Senior Center): Tues: 9 am to 3 pmMehlville (Abiding Savior Lutheran Church): Tues and Th: 10 am to noonSt. Charles (The Care Service): Fri: 9 am to 3 pmSt. Louis City Soulard (Love in Action Heath and Wellness): Tuesday: 10 am to noon.Saint Louis HELP Warehouse (Olivette): Wed and Sat: 9 am to 1:30 pmSt. Louis North City (St. Stanislaus Polish Heritage Church): Fri: 10 am to noon.
Location of Recipient's Residence*

St. Louis CitySt. Louis CountyJefferson CountySt. Charles CountyOther
HOME MEDICAL EQUIPMENT REQUESTED: PLEASE DESCRIBE YOUR CLIENT'S NEED*
HME, describe what you need
Check the items:

BedBed AlarmBed RailBedside CommodeBedside TableBicycle PeddlerCanesCpapCrutchesDry Shampoo, CreamsElevated Leg PadElevated Toilet SeatGait beltsGait TrainerGeriatric ChairGloves (box)Grab BarHoyer Lift/slingIce Therapy MachineIncontinence ProductsKnee/Ankle BraceKnee ScooterLeg Lift Pad holderLift ChairMattress, airMattress, hospitalPediatric EquipmentPower ChairsPower scooterRaised Toilet SeatReacherRoho Cushion/Bed TopperRollatorShoe HornShower BenchShower ChairShower Seat/StoolSit to StandSlide BoardSock pullerTilt-n-space wheelchairToilet safety railsTrapezeTub Transfer BenchTub safety railsWalkerWalker accessories, basketWheelchair, ManualWheelchair, TransferWound Care Supplies

IMPORTANT: PLEASE ENTER 1 NEXT TO EACH ITEM YOU ARE REQUESTING. IF YOU REQUIRE MORE THAN ONE OF THE SAME ITEM, PLEASE TYPE IN THE CORRECT NUMBER. *

	QTY
Bed
Bed Alarm
Bed Rail
Bedside Commode
Bedside Table
Bicycle Peddler
Canes
N/A
Crutches
Dry Shampoo, Creams
Elevated Leg Pad
Elevated Toilet Seat
Gait belts
Gait Trainer
Geriatric Chair
Gloves (box)
Grab Bar
Hoyer Lift/sling
Ice Therapy Machine
Incontinence Products
Knee/Ankle Brace
Knee Scooter
Leg Lift Pad holder
Lift Chair
Mattress, air
Mattress, hospital
Pediatric Equipment
N/A
N/A
Raised Toilet Seat
Reacher
Roho Cushion/Bed Topper
Rollator
Shoe Horn
Shower Bench
Shower Chair
Shower Seat/Stool
Sit to Stand
Slide Board
Sock puller
Tilt-n-space wheelchair
Toilet safety rails
Trapeze
Tub Transfer Bench
Tub safety rails
Walker
Walker accessories, basket
Wheelchair, Manual
Wheelchair, Transfer
Wound Care Supplies

	QTY	Weight	Price $
Bed
Bed Alarm
Bed Rail
Bedside Commode
Bedside Table
Bicycle Peddler
Canes
N/A
Crutches
Dry Shampoo, Creams
Elevated Leg Pad
Elevated Toilet Seat
Gait belts
Gait Trainer
Geriatric Chair
Gloves (box)
Grab Bar
Hoyer Lift/sling
Ice Therapy Machine
Incontinence Products
Knee/Ankle Brace
Knee Scooter
Leg Lift Pad holder
Lift Chair
Mattress, air
Mattress, hospital
Pediatric Equipment
N/A
N/A
Raised Toilet Seat
Reacher
Roho Cushion/Bed Topper
Rollator
Shoe Horn
Shower Bench
Shower Chair
Shower Seat/Stool
Sit to Stand
Slide Board
Sock puller
Tilt-n-space wheelchair
Toilet safety rails
Trapeze
Tub Transfer Bench
Tub safety rails
Walker
Walker accessories, basket
Wheelchair, Manual
Wheelchair, Transfer
Wound Care Supplies
Total

Patient's Height*
Patient's Height
Patient's Weight*
Patient's Weight
Patient's Email Address*
Notification will be sent to this email. If recipient doesn't have an email please provide the caregiver's.
Patient's Phone Number
Please enter a valid phone number.
Client's weight*
Patient's age:*

Prenatal - 45-1011-1314-1819-2425 - 3435 - 5960 to 6465 and over
Is the client age 65 or older

YesNo
Is the Patient a Veteran?*

YesNoI decline
Is patient age 65 or older?*

YesNo
Is patient age 65 or older? NOOO

YesNo
Ethnicity of Patient

African AmericanCaucasianLatino, HispanicAsian/Pacific IslanderI decline to say
Your patient's gender*
"Does the recipient currently receive any federal benefits, such as Social Security, Supplemental Security Income (SSI), SNAP (food stamps), or Housing Assistance?"

YesNo
Patient 's Estimated Income:*

Less than $10,000$10,001-$20,000$20,001-$40,000$40,000-$60,000Greater than $60,000I decline to say
Patient's Ethnicity

AsianBi Racial - Multi RacialBlack or African AmericanHispanic/Latino/a/xMiddle Eastern or North AfricanNative American or Alaska NativeNative Hawaiian or Other Pacific IslanderWhiteOther
How did you learn of the St. Louis Health Equipment Lending Program?*

FriendCaregiverHealthcare professionalFacebook/social mediawww.stlhelp.orgOther
Select all that apply. Why did you contact the St. Louis Health Equipment Lending Program for health equipment*

High co-paysWait time too longYou are healthcare professional needing to help a clientNo insuranceMedicare not approvedMedicaid not approvedOther
The St. Louis Health Equipment Lending Program (STLHELP) relies on the public to support us financially through donations. Will you make a donation to STLHELP to help keep this program?

Yes, I can donate.No, I am unable to give at this time.
Healthcare Professional's Name (pick up person)*
Name of person who will pick up equipment
Healthcare Professional's Phone *
Please enter a valid phone number.
Healthcare Professional's Email Address*
example@example.com
Healthcare Professional's Place of Work *
Healthcare Professional's Business Address NO

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Equipment Lending Agreement

(to be signed by potential recipients or their representative)
(please read and type signature when prompted)

This agreement is a release of the recipient’s rights to sue St. Louis Health Equipment Lending Program Inc., a Missouri nonprofit corporation (“STL HELP”), for injuries, death, or property damage resulting from the loaned equipment (the “Equipment”). The recipient acknowledges that the use of used medical equipment inherently involves certain risks and dangers that can cause personal injury, death, and property damage, including but not limited to mechanical failure, electrical failure, user error, and unforeseen complications arising from the use of such equipment. The recipient expressly assumes all risks related in any way to the use of the Equipment.

The recipient acknowledges that the Equipment is in good working condition and that he/she has examined the Equipment to inspect its condition and identify any defects. The Equipment is loaned at no charge and should be returned by the recipient clean and in good condition when no longer needed. The recipient accepts the Equipment as-is and with all faults. STL HELP EXPRESSLY DISCLAIMS ALL WARRANTIES, WHETHER EXPRESS OR IMPLIED, INCLUDING ANY WARRANTY OF MERCHANTABILITY OR FITNESS FOR ANY PARTICULAR PURPOSE.

By signing this agreement, the recipient agrees to exempt and release STL HELP and its employees, officers, directors, volunteers and agents (“Released Parties”) from all liability and responsibility in any way for personal injury, property damage, or wrongful death to the recipient or his/her family, heirs, and assigns which may occur as a result of receiving and using the Equipment, however caused, including but not limited to product defect or the negligence of any party, including the Released Parties, whether passive or active.

I have carefully read and understand the above agreement and acknowledge that I am the recipient of the Equipment.
Name

First NameLast Name
Signature required*

Clear
Date*

MonthDayYear
Should be Empty:

STLHELP HOME MEDICAL EQUIPMENT