Project Mend Intake Application Form – Fill Out and Use This PDF

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