ROTARY CLUB OF PORTLAND

PORTLAND ROTARY CHARITABLE TRUST

Wheels of Power Application

Dear Applicant:

The Wheels of Power program has a limited territory.

You must reside in one of the following zip code areas in order to apply:

97005 / 97006 / 97007 / 97015 / 97027 / 97034
97035 / 97201 / 97202 / 97203 / 97204 / 97205
97206 / 97207 / 97208 / 97209 / 97210 / 97211
97212 / 97213 / 97214 / 97215 / 97216 / 97217
97218 / 97219 / 97220 / 97221 / 97222 / 97223
97224 / 97225 / 97227 / 97229 / 97230 / 97231
97232 / 97233 / 97236 / 97242 / 97266 / 97267
97239 / 97008 / 97030

The attached application must be completed in as much detail as possible. Lack of information on any particular point can slow down the process. Complete information on insurance, Medicare (including case number), Welfare, Veterans Compensation, Social Security or other possible forms of funding must be included. Identification numbers, names of persons to contact who are familiar with the case and other complete details will assist those screening your application.

Please note that your application will not be considered without a doctor’s prescription along with details of your case. See page three of the application form. The doctor’s information, either on page three of application and/or on separate documents must include:

1)  Diagnosis

2)  Prognosis

3)  Equipment needed

4)  Medical necessity of the equipment

5)  Length of time needed

Once your application is complete, it will be forwarded to the Wheels of Power committee for consideration. The committee will then contact you for an interview. Please note the review process can take anywhere from two to four months after the complete application is received.

Mail application to: Fax to:

Rotary Club of Portland -or- 503.226.7048

1220 SW Morrison St., Suite 425

Portland, OR 97205

Please note:

In order to be considered, applications must be mailed or faxed ONLY

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Wheels of Power Application

Date:______

Have you received a power chair or scooter through Wheels of Power before? ______

If so, was it within the last five years? ______

I.  General Information

a. Applicant______

Address______

City & Zip______

Phone______

Parents or Guardian______

Age_____ Date of Birth______Height______Weight______

Disabling Condition ______

b.  Person other than parent or guardian involved with Home Care:

Name______

Address______Phone______

c.  Other person or organization involved with care:

Name______

Address ______Phone______

d.  Family physician:

Name______

Address______Phone______

II.  Existing or Potential Sources of Assistance

a.  Insurance Company______

Address______Phone______

b.  Other assistance programs i.e.: Welfare, Social Security, Medicare, Etc. (Use additional page if necessary.)

Organization______

Phone______

Address______

Contact Person______

Organization______

Phone______

Address______

Contact Person______

c.  Why have you not secured a power wheelchair/scooter previously?

______

III.  Environment Situation

a.  Is your home accessible for a power chair? Explain.

______

b.  What problem do you currently encounter in your home by using a wheelchair? ______

______

c.  What method of transportation do you use outside of your home?

___Standard Automobile ___Van ___Ramps ___Lift

___Public Transportation

d.  Do you attend school?______

Where? ______Grade______

e.  Are you employed? ______

Employer______

Address______Phone______

IV.  Physical Condition

a.  What other orthopedic equipment do you now use?

______

b.  How would you benefit if you acquired a power wheelchair? Where would you use it and how would you use it?

______

______

c.  How long will you need a power wheelchair?______

d.  What type of power wheelchair are you requesting? ______


TO BE COMPLETED BY YOUR PHYSICIAN

V.  Prescribing and Attending Physician

Name______Phone______

Address______

Patient’s name______

a.  Prescription power wheelchair:

q  Power Chair Only

q  Power Scooter Only

q  Either Chair or Scooter

q  Needed Accessories:

______

______

b.  Statement of diagnosis:

c.  Description of current physical condition:

d.  Physician’s statement of need for a power wheelchair:

** You may attach additional pages for thorough information **

If information is completed on this page, sign below.

______

Prescribing and Attending Physician

Return to: Rotary Club of Portland

Wheels of Power

1220 SW Morrison St., Suite 425

Portland, OR 97205

Or fax to: 503.226.7048
VI. Financial Statement

Request for financial information from applicant, or applicant’s parent or guardian.

Name (First) / Name (Last) / Birthdate
Address / Family Size / Home Phone
City, Zip / Marital Status / Other Income such as Soc. Security, Welfare, or Spousal income:
Amount per month $______
Source
Amount per month$______
Source
Employer / Gross Income Per
Month
Address / Occupation
Employer’s Phone / Years of Service
Medical Insurance
______Yes ______No / Medicare
______Yes ______No
Name of Insurance Company / HMO
______Yes ______No / Name of HMO
Assets / Amount / Outstanding Debt / Amount / Monthly Payments
Cash / Notes Payable:
Bank (1)
Savings Bonds / Bank (2)
Finance Co. (1)
Other Securities / Finance Co. (2)
Real Estate (Market Value) / Credit Cards (Bank & Other)
(1) / (1)
(2) / (2)
(3)
Automobile(s) / Taxes owing
Furniture & Household Goods / Real Estate Loan
Other Assets: / Other Liabilities:
(1) / (1)
(2) / (2)
(3) / (3)
(4) / (4)
Total / Total

I certify that the above statements are true and that no unfavorable information known to me has been omitted. I authorize you to retain this information whether or not I receive a wheelchair from the Rotary Club of Portland.

______

Signature Date

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