Power Wheelchair Application

Power Wheelchair Application

Thank you for your interest in our Power Wheelchair Project. Unlocking Access helps individuals obtain essential mobility equipment when insurance and other funding sources are unable to meet their needs. To be considered, applicants must complete all sections of this application and upload the required documentation, including: an Insurance Denial Letter, Letter of Medical Necessity, and Seating Evaluation that indicates fitting needs and verifies you are physically and mentally able to safely operate the equipment requested. Additional documentation may be requested. By submitting this application, you certify that all information provided is complete, accurate, and truthful. You also affirm that all available insurance options have been explored and exhausted, including Medicaid, Medicare, and private insurance. Incomplete applications or applications missing required documentation will not be reviewed. We appreciate the time and care taken to complete this application and look forward to reviewing your request. --- For any questions about the application please email info@unlockingaccess.org.
Tell Us Who Is Completing This Form
Client Name

First NameLast Name
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact Email
example@example.com
Preferred Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Age of Client

Client Diagnosis
I verify all options to obtain insurance coverage (Medicare, Medicaid, private insurance) has been exhausted. I will provide documentation of insurance denial.
Select type of insurance coverage currently held

Statement of Need: Tell us your story! Share how a power wheelchair would make a difference in your daily life, the challenges you currently face, and the opportunities greater mobility could unlock. This can be written by you, a caregiver, family member, or healthcare provider.
Your Space: We’d love to get an idea of where you live! Is it a house, apartment, or something more rural like a farm? Do you travel over gravel roads, dirt paths, or uneven ground like grass, hills, or steps? This info helps us understand your needs and to ensure the equipment is compatible. Share anything that helps us understand the terrain and daily mobility around your home.
Does your home have the appropriate modifications to allow the power chair to enter/exit safely?
If Answered "Not Yet, but working on it" above, please indicate date expected for modifications to be completed. *Note that this does not impact the acceptance of your application.
Delivery or Pick Up
Delivery options available in certain areas.

Upload Your Files!

This is a friendly reminder that all required documents must be submitted here! Any incomplete applications will not be reviewed. If you have any questions about the files requested, please email info@unlockingaccess.org.
Insurance Denial / EOB for Medicare / Other Denial

If you do not currently have traditional coverage, please upload a letter explaining details of ineligibility.
Cancelof
Letter of Medical Necessity from Physician, Physical Therapist or Occupational Therapist

Cancelof
Seating Evaluation

Cancelof
Upload CRT Evaluation (if applicable)

Cancelof

Agreement & Signatures

Please read the following statements below. We know it's boring, but you are almost done!
Equipment Acceptance and Liability Agreement
The applicant understands that submitting an application to Unlocking Access does not guarantee approval or receipt of equipment.

All equipment provided by Unlocking Access is donated and is provided in "as-is" condition, with no warranties or guarantees, express or implied, regarding its condition, performance, safety, suitability, or fitness for a particular purpose.

Equipment Inspection and Acceptance
Prior to accepting the equipment, the recipient will have the opportunity to inspect the equipment and note any visible defects, damage, wear, or operational concerns. By accepting delivery or taking possession of the equipment, the recipient acknowledges that they have had the opportunity to inspect the equipment and agree to accept it in its current condition, including any known or unknown defects.

Responsibility for Equipment
Upon acceptance, the recipient assumes full responsibility for the equipment, including its use, operation, storage, maintenance, and transportation.

The recipient understands and agrees that they are solely responsible for any future repairs, maintenance, replacement parts, batteries, modifications, servicing, inspections, or other costs associated with the equipment after it has been received.

Unlocking Access is not responsible for providing ongoing maintenance, repairs, technical support, replacement equipment, or funding for future equipment-related expenses.

Assumption of Risk
The recipient understands that the use of mobility equipment carries inherent risks, including the risk of injury, property damage, equipment malfunction, or other unforeseen events. The recipient voluntarily assumes all risks associated with the use, operation, possession, and maintenance of the equipment.

Release of Liability
To the fullest extent permitted by law, the recipient releases, waives, and discharges Unlocking Access and its current and former officers, directors, employees, volunteers, agents, contractors, representatives, and affiliated organizations (collectively, the "Released Parties") from any and all claims, liabilities, demands, damages, losses, costs, expenses, or causes of action arising from or related to the equipment, including but not limited to injuries, property damage, equipment failure, or other incidents resulting from its use, possession, transportation, maintenance, or operation.

The recipient is responsible for ensuring that the equipment is properly fitted, programmed, and used in accordance with recommendations from their healthcare provider, therapist, or equipment specialist.

Waiver of Future Claims
The recipient agrees not to initiate, file, or pursue any legal claim, lawsuit, or other action against any Released Party arising from or related to the equipment or its use.

By signing below, the recipient acknowledges that they have read, understood, and voluntarily agreed to the terms of this Equipment Acceptance and Liability Agreement.

Media Release and Consent Agreement
I grant Unlocking Access and its affiliates, partners, successors, assigns, employees, contractors, agents, and representatives ("Unlocking Access") permission to use my name, image, likeness, voice, and appearance as captured in photographs, videos, audio recordings, digital images, testimonials, or other media ("Materials").

I understand and agree that these Materials may be used by Unlocking Access for educational, promotional, fundraising, marketing, reporting, and other lawful purposes in print, online, social media, and other forms of communication. I understand that these Materials may be distributed worldwide and may remain in use indefinitely.

By signing this agreement, I waive the right to inspect, review, or approve any finished materials or future uses of the Materials. I understand that I will not receive compensation for the use of my name, image, likeness, voice, or appearance.

I release and hold harmless Unlocking Access from any and all claims, demands, liabilities, or causes of action arising from or related to the use of the Materials, including but not limited to claims involving defamation, invasion of privacy, rights of publicity, or similar matters, whether currently known or discovered in the future.

Parent or Guardian Consent for Minors
If the participant is under the age of 18, the parent or legal guardian must sign below. As the parent or legal guardian of the minor participant, I grant all permissions and rights described in this agreement on behalf of the minor and myself. I represent that I have the legal authority to provide this consent and agree to indemnify and hold harmless Unlocking Access from any claims or liabilities resulting from a lack of such authority.

Certification and Acceptance: I certify that the information contained herein is true and complete and accept the obligation to comply with the terms and conditions if the request is awarded as a result of this application. I understand that falsifying information, omitting relevant information, or failing to provide requested documentation will result in denial of my application.

Submission of this application does not guarantee approval, and nothing in this form should be interpreted, directly or indirectly, as a promise or assurance that my application will be approved.

Non-Discrimination: Unlocking Access will not make contributions that discriminate on the basis of race, color, religion, gender, sexual orientation, national origin, age, citizenship, veteran/reserve/national guard status, or other protected status; partisan political organization; or groups limited to members of a single religious organization.
Signature
Printed Name of Signer

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Power Wheelchair Application

Upload Your Files!

Agreement & Signatures