APPLICATION
SPECIAL NEEDS EQUIPMENT FUND
Please read the Application Guidelines before completing this application
Please send applications to United Way of Palm Beach County.
Name of Client: Sex: Age:
Date of Birth:
Disability and/or diagnosis:
Method of Mobility:
Method of Communication:
Race/Ethnicity
White non-Hispanic ____ Native Hawaiian/Pacific Islander ______
Black non-Hispanic _____ American Indian/Alaskan Native ______
Haitian (of any race) _____ Multiracial/Multiethnic (two or more races or ethnicities) _____
Hispanic (of any race) _____ Other ______
Asian ______Unknown ______
Parent(s)/Guardian Name:
Address:
Zip: Phone:
Email address:
Household Income (reference attached table):
At or below 100% of the Federal Poverty Level ____
101% of the Federal Poverty Level _____
Above 225% of the Federal Poverty Level ______
Unknown ______
Name of Submitting Agency:
Address:
Contact Person/Therapist:
Phone: Fax:
E-mail Address:
1. Complete this section.
a) Describe the specific equipment that is being requested/recommended. (Please attach a photo of equipment.)
__
b) Describe how this equipment will assist the child.
c) Who identified the need for this type of equipment?
d) Approximately how long will the equipment be used?
2. Has Clinics Can Help been contacted to see if the requested equipment is available free of charge? (561-640-2995) Note: This is required for many items – see guidelines.
Has the child requested or received equipment from United Way of Palm Beach County Special Needs Equipment Fund or the Children’s Services Council Special Needs Equipment Fund in the past? (YES/NO)
If so, please give an approximate date, type of equipment received.
Was this equipment donated to a lending closet, such as Clinics Can Help, after use? (YES/NO)
If no, please explain.
3. The child (HAS/HAS NOT) tried this equipment. If not, why?
4. Is the child eligible for: Will agency pay for the equipment requested?
Private Insurance YES NO YES NO
Medicaid YES NO YES NO
APD (Agency for Persons with YES NO YES NO
Disabilities) Medicaid Waiver
Children’s Medical Services YES NO YES NO
Vocational Rehabilitation
(16 yrs. or older) YES NO YES NO
School District (Hearing Aids) YES NO YES NO
Other: YES NO YES NO
If answering yes to any of the above, but funding is not provided by that agency, please explain below. Note: A letter of denial from the declining agency (e.g. Medicaid, insurer) must be submitted for most items (see Application Guidelines.)
5. For each item requested, attach a price quote from each vendor/manufacturer. Two (2) price quotes are required, except for items requiring custom measurements, such as wheelchairs. If less than the required number of price quotes are available, explain and document vendors approached (see Guidelines for exceptions).
Vendor/manufacturer Price Quote Shipping Cost Total Cost
Name
1. $ $ $
2. $ $ $
Does this equipment come with a warranty? (YES/NO)
If yes, what is the cost? $
Indicate vendor/manufacturer preference and explain.
Total cost of the equipment requested including warranty: $
Amount to be paid by the insurer: $ -
Amount to be paid by civic, religious, community
organizations, or individuals. (List and subtract from total). $ -
______
______
Balance to be paid by the Equipment Fund: $
Amount of family’s contribution: $______
In the event the purchase price of the requested equipment exceeds the amount of the Equipment Fund cap, please refer to the Application Guidelines.
NOTE: United Way of Palm Beach County Special Needs Equipment Fund awards are paid out in full to chosen vendor. Please review the Application Guidelines for proof of purchase policy.
6. Please attach the following items to this application form:
□ Two (2) vendor/manufacturer written price quotes of the exact cost of the equipment for requests, except for custom items such as power wheelchairs, submit one quote.
Note: If this is the sole vendor/manufacturer for the piece of equipment being requested, please refer to the Application Guidelines.
□ The appropriate documentation (e.g. letter of medical necessity, etc.) from a licensed/certified provider who is knowledgeable of the child’s condition.
□ Medicaid or insurance denial letter, where required.
□ Photo of the equipment
Choose an item.
I understand that approval of this request rests with the Special Needs Equipment Fund Committee.
By signing the application, the submitting public service agency, treating therapist and the applicant’s family declares that the family is in need, has no other means to obtain the equipment, and will authorize release of any information to substantiate the request if necessary.
They further declare that the equipment purchased will be used for the sole purpose for which it has been requested. Any misuse of equipment is not acceptable and will be brought to the attention of the appropriate persons.
The applicant’s family also agrees that, to the best of its ability, it will seek to donate the equipment to Clinics Can Help once it is no longer being used. Finally, the family agrees that United Way may provide its contact information to Clinic Can Help and that Clinics Can Help may call periodically to inquire as to whether the equipment is still being used.
Signature of Treating Therapist Date
Signature of Parent or Guardian Date
RETURN TO: United Way of Palm Beach County
Attn: Pam Heyer, Special Needs Equipment Fund
477 S. Rosemary Avenue, Suite 230
West Palm Beach, FL 33401
561-375-6650
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