Project Mend Intake Application Form PDF Details

The Project Mend Intake Application form represents a critical step towards securing durable medical equipment and fitted mobility services for individuals in need. Created to ensure that essential equipment reaches those who require assistance for mobility and daily activities, the form carefully gathers detailed information. Starting with basic identification and contact details, it progresses to in-depth queries about the applicant's medical diagnosis, physical characteristics, and demographic information, emphasizing a comprehensive understanding of the applicant's situation. Moreover, it takes into account the applicant’s living arrangements, income sources, and insurance coverage, ensuring a holistic assessment of their circumstances. The form also outlines the terms of the service agreement, highlighting the recipient's responsibilities towards the maintenance and appropriate use of the provided equipment. It incorporates a waiver and release of liability, a media release statement, and income eligibility certification, addressing legal considerations and consent for publicity. Project Mend’s commitment to supporting individuals with mobility challenges is evident in the thoroughness of this application process, aiming to match services and equipment with the needs identified by healthcare professionals.

QuestionAnswer
Form NameProject Mend Intake Application Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesCARELINK, 2009, DME, project mend in san antonio

Form Preview Example

PROJECT MEND

INTAKE APPLICATION

DURABLE MEDICAL EQUIPMENT SERVICE

 

FITTED MOBILITY SERVICE

 

 

 

 

 

 

DATE

 

 

 

REFERRED BY

 

 

 

 

 

 

 

NAME

 

 

COUNCIL DIST. #

PRECINCT#

 

 

 

 

 

ADDRESS

 

 

COUNTY

 

 

 

 

 

 

 

CITY

STATE

ZIP CODE

 

DATE OF BIRTH

 

 

 

 

 

 

AGE:

 

 

 

 

 

 

TELEPHONE

 

 

 

SOCIAL

 

 

 

 

 

SECURITY #

 

 

 

 

 

 

 

DIAGNOSIS

MR #

 

 

HEIGHT

WEIGHT

 

 

 

 

 

 

CLIENT DEMOGRAPHICS

(Please check appropriate box)

 

 

 

GENDER

Male

 

 

Female

 

 

Female Head of Household

 

VETERAN, MILITARY PERSONNEL,

YES

 

FAMILY MEMBER

NO

 

AGE GROUP

0-18

 

 

19-34

 

 

35-59

 

 

60+

 

ETHNICITY

White/Anglo

 

 

Hispanic/Spanish

 

 

African American/Black

 

 

A.Indian/Eskimo/Aleut/Othr

 

INSURANCE

Medicaid

 

 

Medicare

 

 

County Hospital (CARELINK,

 

 

GOLD CARD, NUECES AID, etc.)

 

 

Veteran’s Insurance

 

 

Private Insurance

 

 

None

 

LIVING ARRANGEMENTS

Alone

 

 

W/ Spouse

 

 

W/ Family

 

 

W/ Non-Family

 

 

Nursing/Retirement Facility

 

 

Homeless

 

MONTHLY INCOME SOURCE(S)

VET, Military, Family: EXEMPT INCOME

COSA CDBG: LIMITED CLIENTELE

SSI / SSDI:

AFDC/TANF:

Child Support:

Family/Friends:

Wages/Salary:

Pension/Retirement:

Other:

TTL Monthly Income:

Annual Income:

***If ZERO income, Narrative Required on Income

Certification Form***

PROJECT MEND STAFF ONLY:

COSA-CDBG Bexar County

ALAMO AREA (UT)

JEREMIAH

Children

Other Area (UT)

COASTAL BEND(UT)

Alcoa

Greehey

 

Updated: 03/17/2010

Page 1 of 4

 

SERVICE AGREEMENT

Project MEND agrees to provide

_

the refurbished equipment

listed below to assist you in increasing your mobility needs that have been identified by your doctor.

Item ID

Equipment

Size

Quantity

Inventory Number Donation Date of Issuance

Conditions of the Service Agreement:

By signing this agreement and accepting the issued equipment you agree to: (Please initial the following)

_____Keep the equipment at the address you have provided and to notify Project MEND of your new

address and phone number should you move or should your phone number change.

_____Be responsible for any repairs and maintenance to the equipment after the 30 day expiration date.

_____That you will not transfer/loan or give this equipment to any other person or allow any other person to

use this equipment which has been deemed a medical necessity by your physician.

_____Use the equipment as your doctor has recommended for medical purposes or rehabilitation.

_____Use the equipment in the manner recommended by the original manufacturer of the equipment.

_____Accept full responsibility and indemnify and hold harmless Project MEND and its partner agencies

against all claims, costs, expenses, damages and liability resulting from or pertaining to the use or operation of the equipment during the term of this agreement while you use this equipment.

_____I acknowledge that I have received printed instructions for the issued equipment.

_____I understand that the equipment I am receiving from Project MEND has been donated and therefore

does not come with any manufacturer warranties or guarantees.

_____Recipient acknowledges that the equipment is in good working condition and that he/she has

examined the equipment to inspect its condition and identify any defects.

_____I have read and understand that this is a service agreement and not a contract for sale or purchase

of this equipment.

 

 

 

 

 

 

Client/Representative:

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

Project MEND Staff:

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

PROJECT MEND Staff ONLY:

 

 

 

 

 

 

Original Intake Date:

Original Grant:

Current GRANT: ____________________

 

 

 

 

 

 

 

 

 

 

Page 2 of 4

EQUIPMENT POLICIES & FEES

(Effective September 1, 2009 the following fees apply to all clients completing an application for services)

PROCESSING FEE

A $20.00 processing fee will apply to all clients completing an application for services.

30 DAY REPAIR POLICY

 

 

Project MEND will repair or replace all DME from the original date of intake up to this 30 day expiration date:

_.

*After the above 30 day expiration date, all clients are responsible for the Standardized Repair Fee of $50.00.

 

 

ELECTRIC HOSPITAL BEDS

Project MEND will issue only one Electric Hospital Bed once every 12 months. The 30 day repair and replacement policy will apply towards any and all items related to the Electric Hospital Bed including but not limited to: Bed frame, Bed rails, Mattress, and Controller.

ELECTRIC WHEELCHAIRS AND SCOOTERS

Project MEND will issue only one Electric Wheelchair or Scooter once every two years. The 30 day repair and replacement policy will apply towards any and all items related to Electric Wheelchairs and Scooters.

BATTERIES

Electric Wheelchairs and Scooters are issued with a set of brand new batteries. Clients are responsible for the purchase of these batteries. These fees vary and are based on battery size/model.

12v, 12amp = $34.00 each

12v, 18amp = $43.00 each

8AU1 = $64.00 each

8AU22NF = $105.00 each

REPAIRS (Within Bexar County Only) Project MEND only repairs medical equipment that has been issued from our warehouse. Standardized Repair Fee: $50.00

DELIVERIES (Within Bexar County Only)

Inside Loop 1604:

$25.00

Outside Loop 1604:

$50.00

ALL FEES ARE SUBJECT TO CHANGE.

Additional fees for all deliveries outside of Bexar County will be calculated based on distance and travel time. Please contact our office for rates.

Client/Representative:

 

Date:

Project MEND Staff:

 

 

Date:

WAIVER AND RELEASE OF LIABILITY

I, __________________________________________ have carefully read and understand that by signing this agreement, EXEMPT and RELEASE

(PRINT NAME)

PROJECT MEND and COLLABORATING PARTNERS and ALL RELATED ENTITIES FROM ALL LIABILITY OR PERSONAL RESPONSIBILITY WHATSOEVER FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH AS A RESULT OF ACCEPTING AND RECEIVING DONATED, DISTRIBUTED, OR REPAIRED EQUIPMENT, HOWEVER CAUSED, INCLUDING, BUT NOT LIMITED TO PRODUCT LIABILITY OR NEGLEGENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE.

_____________________________________

 

_____

________________________

 

Client/Representative

 

 

 

 

 

Date

 

 

___________________________________________

 

 

 

________________________

 

 

Project Mend Staff

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 3 of 4

INCOME ELIGIBILITY CERTIFICATION

Client Name

1.I do hereby certify that I have provided, to the best of my knowledge, the total gross annual income received during the past 12

months required to determine eligibility to participate in any Project MEND related program. $

 

____

,

 

 

 

 

 

 

 

 

 

 

 

annually. I understand that information in regards to my gross income is necessary to determine eligibility.

 

2. Including yourself, how many persons live in your household?

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___

 

Client or Representative

 

(Relationship to Client)

 

 

 

 

 

Date

 

 

 

 

 

_______________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

Project MEND Staff Signature

 

 

 

 

 

 

Date

 

 

 

 

 

FY 2009 Income Limit Area

FY 2009 Income Limit Category

1

 

2

3

4

 

5

6

 

7

 

8

Person

Person

Person

Person

Person

Person

Person

Person

 

 

 

Very Low (50%) Income Limits

$20,000

 

$22,900

$25,750

$28,600

$30,900

$33,200

$35,450

$37,750

Bexar County

Extremely Low (30%) Income

$12,000

 

$13,700

$15,450

$17,150

$18,500

$19,900

$21,250

$22,650

Limits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Low (80%) Income Limits

$32,050

 

$36,600

$41,200

$45,750

$49,400

$53,050

$56,750

$60,400

NOTE: Bexar County is part of the SAN ANTONIO, TX HUD METRO FMR AREA. The SAN ANTONIO, TX HUD METRO FMR AREA contains the following areas: Bandera County, TX ; Bexar County, TX ; Comal County, TX ; Guadalupe County, TX ; and Wilson County, TX . Income Limit areas are based on FY 2009 Fair Market Rent (FMR) areas. For a detailed account of how this area is derived please see our associated FY 2009 Fair Market Rent documentation system.

IF NO INCOME, PROVIDE SELF CERTIFICATION OF FINANCIAL SUPPORT:

________

_____

___

MEDIA RELEASE STATEMENT

By my signature on this form, I acknowledge receipt of this document and give permission to Project MEND and its designee to use such reproductions for educational and publicity purposes in perpetuity without further consideration from me.

I understand that I will need to notify Project MEND if any changes to my situation occur that will impact this media release permission.

I have read the above release and am aware of its contents.

Signed: __________________

 

__________________

 

Date ____

___________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Print Name: ___

 

 

 

_______________________________________________________

 

 

Address: ___________

 

__________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone: _______

 

 

__________________

 

Email: ____________

______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLIENT DENIED MEDIA RELEASE

Page 4 of 4

How to Edit Project Mend Intake Application Form Online for Free

You'll be able to fill out 2009 without difficulty using our online PDF editor. The editor is constantly updated by our staff, getting new functions and growing to be better. To get the ball rolling, go through these basic steps:

Step 1: Press the "Get Form" button above. It's going to open up our tool so that you could start completing your form.

Step 2: The editor helps you customize PDF files in various ways. Transform it by writing customized text, correct what's already in the document, and include a signature - all readily available!

Filling out this PDF generally requires attentiveness. Make certain every blank is completed accurately.

1. The 2009 usually requires particular information to be entered. Be sure the subsequent fields are filled out:

Filling out part 1 of TX

2. After this section is completed, go on to enter the suitable details in these - AGE GROUP, ETHNICITY, INSURANCE, LIVING ARRANGEMENTS, Male Female Female Head of, VET Military Family EXEMPT INCOME, If ZERO income Narrative Required, and Certification Form.

Writing part 2 in TX

3. Completing PROJECT MEND STAFF ONLY, COSACDBG Bexar County, JEREMIAH Other Area UT COASTAL, ALAMO AREA UT Children Alcoa, Updated, and Page of is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Completing segment 3 in TX

As to COSACDBG Bexar County and JEREMIAH Other Area UT COASTAL, ensure you get them right in this section. These are surely the most important fields in the page.

4. This next section requires some additional information. Ensure you complete all the necessary fields - Project MEND agrees to provide, the refurbished equipment, Item ID, Equipment, Size, Quantity, Inventory Number Donation Date of, and Conditions of the Service - to proceed further in your process!

TX conclusion process described (part 4)

5. Since you get close to the end of your file, there are a couple extra requirements that need to be fulfilled. Specifically, address and phone number should, Conditions of the Service, use this equipment which has been, I acknowledge that I have received, examined the equipment to inspect, of this equipment, ClientRepresentative Project MEND, Date, Date, and PROJECT MEND Staff ONLY Original must be filled out.

Date, Date, and of this equipment of TX

Step 3: After double-checking your entries, hit "Done" and you're good to go! Go for a 7-day free trial option at FormsPal and get immediate access to 2009 - download, email, or edit inside your personal account. With FormsPal, you can fill out documents without the need to get worried about database breaches or records being distributed. Our secure platform ensures that your private information is stored safe.