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Mannys Caring Hands Disclaimer and Application for Durable

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Mannys Caring Hands Disclaimer and Application for Durable Powered By Docstoc
					                               Manny’s Caring Hands
                                      38224 Stevens Road
                                  Lovettsville, Virginia 20180
                              (540) 822-5619, fax (540) 822-4146
                               manny@mannys-caringhands.org




                      Disclaimer and Application
             for Durable Medical and Computer Equipment


These two documents are required by Manny’s Caring Hands for processing and evaluating
requests for Durable Medical and Computer Equipment. Please be as accurate and complete as
possible in filling out these documents. Although some of the information may seem to be
duplicated on each form, this information is handled and evaluated by different persons. Please
understand that we know how complicated and time consuming forms can be, but it is essential
for Manny’s Caring Hands to be as thorough and complete as possible to ensure fairness and
equity to both our recipients of this equipment and those who so generously donate this equip-
ment.
                                                 Disclaimer
Name

Address




Date


Gail Kelley
Manny’s Caring Hands
38224 Stevens Road
Lovettsville, Virginia 20180

Re: Application for Durable Medical and Computer Equipment — circle one

Dear Gail:

We are writing in response to your availability of Durable Medical and Computer Equipment for our child.

Our child is [describe child and medical condition].




We are requesting [describe equipment needed] ______________________________equipment. Our need for
the equipment is to [describe need and anticipated use of equipment].__________________________________



Our financial situation affecting our ability (or inability) to purchase such equipment is [describe financial
situation].



Our insurance company has responded to our request for such equipment by saying [describe insurance
company’s response].




                                                                                                         continued
Disclaimer page 2

In addition, as you consider this application request for such equipment, we think it would be helpful for you to
know that [describe any additional and pertinent information that Manny’s Caring Hands would need in order
to award the piece of Durable Medical or Computer Equipment you are requesting].




We understand that this equipment comes without warranty of any kind from Manny’s Caring Hands. In addi-
tion, we agree to hold Manny’s Caring Hands harmless from any liability arising from our and/or our child’s use
of such equipment, and to indemnify and hold harmless Manny’s Caring Hands for any costs or claims arising
from our use of equipment. Manny’s Caring Hands will not be responsible for upkeep, repairs or questions on
said awarded equipment once transfer has taken place. We also understand that there will be a nominal/minimal
processing fee for this equipment, which may include postage and shipping costs. To find out more call
Manny’s Mom at 540-822-4475.

[Additional paragraph or comments you want to make].




Thank you for considering our request.


____________________________________               _____________________________
Special Needs Child’s Signature if Available                     Date


____________________________________               _____________________________
Parents/Caregiver                                               Date
                     Confidential Application for Durable Medical Equipment
                                   and/or Computer Equipment

                                           Manny’s Caring Hands
                                             38224 Stevens Road
                                         Lovettsville, Virginia 20180
                                      (540) 822-5619, fax (540) 822-4146
                                      manny@mannys-caringhands.org


Date:__________________________

Child’s Name: _________________________                     Date of Birth:

Parent/Guardian: _______________________                    Relationship:________________________________

Address:                                                    Home Phone:

                                                            Work Phone:



List all members of the household, their age and relationship to the child:




Physician: ____________________________                     Phone: ____________________________________

Physician: ____________________________                     Phone: ____________________________________



Describe the child’s disability:




                                                                                                continued
Manny’s Caring Hands
Confidential Application for Durable Medical Equipment and/or Computer Equipment



Describe the specific needs that the requested service or equipment will meet and how it will benefit the child.
Include any reports from professionals that support this petition.




How soon do these needs have to be met? Explain:




Is the child covered under any health or medical insurance? ________________

If yes, please give company name and kind of coverage: ____________________________________________

Have you tried to negotiate with your insurance company or sought assistance for acquiring equipment or

service? __________________________________________________________________________________



Is the child enrolled in any Special Education Program or Therapeutic programs? ____________

If yes, please list the name of the facility and a contact person:


Please provide a letter of need and approval from your health care provider (Dr., O.T., P.T., etc.) This letter of
need must be on official letterhead.




                                                                                                          continued
                                                          2
Manny’s Caring Hands
Confidential Application for Durable Medical Equipment and/or Computer Equipment


                                         Monthly Income and Expense Statement

Gross monthly income #1* ____________________                         Gross monthly income #2* ___________________

Less deductions:                                                      Less deductions:
        F.I.C.A.           __________                                         F.I.C.A.           __________
        Fed. Taxes         __________                                         Fed. Taxes         __________
        State Taxes        __________                                         State Taxes        __________
        Insurance          __________                                         Insurance          __________
        Other              __________                                         Other              __________

Net Income:                __________                                 Net Income:                __________

List other sources of income and monthly amount: ___________________________________________________
____________________________________________________________________________________________

* Verification of income is required. Please submit with this application a copy of your last two recent pay stubs. Your application cannot be
processed without this information.



Please state major expenditures in the last year as a result of your child’s disability:




Please include any additional information concerning your child’s needs that may be helpful to Manny’s Caring
Hands Selection Committee in considering your application:




Referral source and signature:

Application completed by: ____________________________________________________________________

Relationship:
                                                           Release of Information
The information in this application is true and accurate to the best of my knowledge. I understand that this information will not be
released or made public in any way, and will be used by Manny’s Caring Hands Selection Committee, only for the purpose of deter-
mining eligibility. I give permission for the Manny’s Caring Hands committee to contact individuals in this application who provide
direct services to my child. This information will be used to review and award Durable Medical Equipment and/or Computer Equip-
ment. Upon receipt of Durable Medical and Computer Equipment, the recipient is solely responsible for all maintenance and
repairs.

                                                                                 __________________________________________________
                                                                                 signature

                                                                                 __________________________________________________
                                                                                 date
                                                                           3