Apply for Assistance....

To apply for assistance, please fill out the following form.  We will contact you to discuss your application and determine what assistance we may be able to provide.  Note that we will try to meet all applicant's needs if possible.

In Order to fill out this form, you will need to upload the following documents in PDF format:

• A written statement from your healthcare provider describing the need for the requested equipment/service

• Detailed documentation of the equipment/service being requested

• Copy of Insurance Claim regarding the equipment/service (if a claim was made)

• Copy of Denial Letter from Insurance Company (if claim was denied)

• Copy of Medicaid Claim regarding the equipment/service (if a claim was made)

• Copy of Denial Letter from Medicaid (if claim was denied)