Medical Equipment Application

By checking below and continuing this application, you are affirming that you live in the area we serve:

I am currently a resident of North Carolina or South Carolina

Preliminary Application for a Wheelchair Van from All Things Possible Medical Fundraising (ATP)

There are 3 phases to this application that are required as part of our vetting process: Preliminary, Documentation, and Financial.

Due to the high cost and limited availability of used wheelchair vans, plus the fact that donors are entrusting us with their funds, we must be very thorough when reviewing applications.

All areas with a * must be filled in throughout the application. If you miss one of these red-starred questions, you will see a red error message pop-up, and you will be unable to continue until completed.

The Process

Preliminary Application: The wheelchair van user, or their assigned advocate, completes the online Preliminary Application. This initiates the start of the vetting process.
Introduction by Phone: After you submit the Preliminary Application, the applicant (or caregiver) will receive an introductory phone call, whereby our Administrative Coordinator will answer any questions you have, and discuss the online application process going forward.
Secure Forms: The agreements and waiver documents will be emailed to the applicant. They are required to be signed and returned to our Administrator before the application process moves ahead.
HIPAA: Our documentation is secure via JotForm and in compliance with HIPAA regulations.
Money Management Inc (MMI): During the final phase, you will also be referred to a nonprofit crediting counseling service, Money Management International, at no cost to you. They will review the information you provide on the Financial Profile piece of the application, as well as pull your credit report to assist with the financial review. This financial counseling service will also provide financial resources and budgeting recommendations.

Initials*I am willing to work with a financial counselor at MMI to examine my credit and to review my current financial situation (This will be at no cost to you.)

Review: Once all information is verified, it will be presented to our Medical Review Team, which includes medical and financial professionals, who will examine all the details. The synopsis and recommendations will be presented to our Board of Directors. Eligibility for a wheelchair van will be determined based upon your responses. The ATP Board of Directors will then vote to determine whether we move forward with gifting you a wheelchair van (once funding and the appropriate van becomes available).
Video: Once approved by the Board of Directors to move ahead, a video interview will be scheduled. This video is for you to tell your story. It will be used as a marketing piece to increase donations. The individual in the wheelchair, as well as their caregiver(s), are required to be present. If the applicant cannot speak clearly, their advocate or caregiver will be interviewed, with the applicant in the room. The video interview will likely be recorded via Zoom, or in some cases at the home of the potential recipient. The decision as to where and how the video interview is conducted is at the discretion of our ATP videographer.
Acceptance: The leadership of ATP reserves the right to accept or decline the application based on necessity, financial information, urgency, and/or the ability to make a significant difference for the patient, as evidenced by the available information. However, if the applicant’s circumstances change or important new information comes to light after acceptance, ATP reserves the right to reverse or amend its decision. The applicant will be notified by phone from one of our associates once an approval decision has been made. If accepted, the next steps will be detailed within that notification call. If declined, the applicant will receive written notification. The decisions of the Board of Directors for ATP are final.
Fundraising Participation: It is expected that the family will participate in ATP fundraising efforts, including sharing information on the mission with friends, family, coworkers, and social media to encourage donations.
Your Financial Responsibility: You are responsible for paying the tax, title, and transfer fees for your vehicle. At the time of possession, the paperwork is completed and you must bring the money for tax, title, and transfer fees, which is payable to Ilderton Conversion Company. That amount is largely based on the price we pay for the vehicle and whether you live in NC or SC. The exact amount due (generally between $2,000 and $2,400) will be told to you in advance. These funds must be readily available to you (in checking or savings account).

Will you have these funds available within 30 days of submitting this application?*

YesNo

The wheelchair owner will be required to pay Personal Property Taxes on the wheelchair van within 30-90 days of ownership and transfer of title. This yearly tax varies based on the state and county you live in and can range from $600, and up. This tax is the sole responsibility of the owner.

Getting Your Van: ATP purchases vehicles from Ilderton Conversion Company and will not be delivered to you. You are responsible for making the arrangements to pick up the vehicle at Ilderton Conversion Co in Charlotte, NC. Both the applicant and driver/owner of this vehicle must be present. The local Charlotte, NC media will often be onsite to record the presentation, along with our own videographer. Ilderton Conversion Company is a wheelchair van/mobility vehicle specific dealership, is family owned, has 4 locations, and has been in business since 1972. Their mobility consultants and service technicians are factory trained and certified. Ilderton Conversion Company is a member of the National Mobility Equipment Dealers Association (NMEDA) and an active participant in NMEDA’s Quality Assurance Program (QAP). Their address is Ilderton Conversion Company, 1424 Archdale Dr, Charlotte, NC 28210, www.ildertonvans.com.

ATP Board of Directors determines whose need is funded next based upon:

Availability of funds
Best match of physical limitations to the type of van that becomes available
Urgency of need

Please continue with our application, and remember to fill-in all areas with an *.

What type of mobility equipment are you requesting from All Things Possible?*

Pre-owned Wheelchair VanRepair to Mobility Components of Current Wheelchair Van (Applicant must take vehicle to one of 4 Ilderton Conversion locations for an estimate and repairs. Those locations include: Asheville, High Point, and Charlotte in North Carolina, or Charleston, South Carolina)

I understand that All Things Possible will only cover the cost of repairs related to mobility components and mechanisms, and not general vehicle maintenance and repairs.*

Yes, I understand this.

Are you requesting a wheelchair van with hand controls?*

NoYes

Disabled Driver

We require applicants requesting wheelchair vans with hand controls, to have a valid driver's license with the #9 restriction (which requires full hand controls) in their possession prior to completing the application.

Do you have the #9 restriction on your valid driver’s license?*

NoYes

Once you have a valid driver’s license with the #9 restriction, you can submit an application.

Have you ever received a wheelchair van from ATP in the past?*

NoYes

Occasionally, there may be circumstances that render a previously gifted van from ATP inoperable. These reasons may include, but are not limited to: an accident resulting in total loss, passage of extended time since last van gift, extenuating circumstances, and more. In such cases, ATP will consider the opportunity to provide another van to a repeat applicant. However, we require additional information from repeat applicants in order to access each case fairly.

Date you received your most recent van from ATP:*

Total number of vans you have received from ATP:*

Provide an explanation as to why your prior van(s) are no longer able to be used.*

Upload any supporting documentation for why your prior van(s) are no longer able to be used. (Insurance records, repair shop quotes, police/accident report, etc.)*

Upload documentation confirming any payments agreed upon and received from an insurance company or third party.*

ATP requires that ALL insurance payouts awarded, due to the loss of your previously gifted van, must be used toward the purchase price of a newly gifted van. Upon the approval of a repeat applicant, ATP will make up the difference between the amount paid by the insurance settlement and the purchase price of the new van selected by our organization.

A repeat applicant is required to go through the full review and reapproval process. In addition to the regular criteria used for determining van eligibility, a repeat applicant may be denied based on the factors resulting in the loss of their prior van(s). These factors include, but are not limited to: being at fault in an accident, owner negligence, noted instances of carelessness, overall disposition of the applicant, etc.

Vans will be awarded based on availability, applicant circumstances, and current applicant pool. First time applicants may be given priority. Van eligibility for returning applicants will be considered on a case-by-case basis by our Medical Committee, Finance Committee, and ultimately the ATP Board of Directors.

Medical Equipment Application

All Things Possible Medical Fundraising currently serves those living in North Carolina and South Carolina.

Preliminary Application for a Wheelchair Van from All Things Possible Medical Fundraising (ATP)

The Process

This is the end of our Phase 1 - Preliminary Application.