Leimkuehler Give Back Form

Leimkuehler Give Back Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

Other
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you Currently a Patient at Leimkuehler O-P?
Are you a US Citizen? (only US citizens are eligible at this time)
Amputation Level
Brief Description of your Case or Mobility Challenges
Why do you need assistance? (Please give us detailed information)
Insurance & Financial Information
Do you Currently Have Insurance? (if NO explain why)
Employment Status
List all Sources of Income

Other
Total Household Monthly Income
Required Uploads

Upload ALL required documentation below. If you cannot provide a document, you must upload a written explanation.
W2 Forms the Previous Year

Cancelof
Last Year's Income Tax Return

Cancelof
Pay Stubs (Last 3 Months) for All Employed Family Members

Cancelof
Evidence of Fixed Income Upload (SS, Disability, Workers’ Comp, Pension, Child Support, etc.)

Cancelof
Checking & Savings Account Statements (Last 3 Months)

Cancelof
If you cannot supply any required documents, write a written explanation.
Assets & Liabilities
Checking Account Total
Savings Account Total
Any Other Assets (cars, property, retirements)
List all debts/liabilities (credit cards, loans, medical bills)
Residency & Travel
Are you traveling from out of state?
State you Currently Live in
Do you need assistance with travel or lodging?
Patient Agreement & Signature
Submission of this application does not guarantee assistance. The LGB program is discretionary and voluntary, based on available funds, manufacturer participation, and clinical evaluation. All information submitted must be accurate and truthful. Providing false information may result in denial.
Signature
Should be Empty:

Leimkuehler Give Back Form

Insurance & Financial Information

Required Uploads

Assets & Liabilities

Residency & Travel

Patient Agreement & Signature