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  •                 PERMOBIL FOUNDATION               PRODUCT APPLICATION

    PERMOBIL FOUNDATION PRODUCT APPLICATION

  • The Permobil Foundation is the philanthropic arm of Permobil and offers assistance for end-users who are denied funding by their insurance for a chair or chair part that is medically necessary for their independence. The Permobil Foundation Board of Directors meet once a month to review all requests. Applications are due by the 20th of each month, no exceptions.

    • Applications must be fully completed along with the uploaded required documents including insurance denial.
    • In order to complete this application you will need the wheelchair dealer/vendor contact information and Permobil quote #

    The submission of this application shall serve as proof that all information is complete and truthful. Further, the applicant certifies that all options to obtain coverage and payment from insurance(s) have been attempted and exhausted. Any incomplete applications will be rejected.

  • CLIENT INFORMATION

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  • Dealer/Wheelchair Vendor Information

    IMPORTANT: Prior to submitting this application the dealer/vendor must have obtained a quote from Permobil and the wheelchair must not be ordered. 
  • INSURANCE INFORMATION

  • IMPORTANT: All insurance options MUST be submitted and denied PRIOR to applying and ducumentation MUST be included with application (attach a copy of any documentation from insurance carrier associated with the claim/denial or attach Medicare/Medicaid DME non-covered DME or LCD)

  • At the bottom of this form you must also attach letter from doctor or physical therapist regarding the medical necessity of request.

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  • The following MUST be submitted with this application or it will be rejected, no exceptions: 

    • Fully completed application with signature of applicant and dealer
    • Permobil Quote # (if you have a copy of wheelchair quote please include with this application)
    • Copy of insurance denials and appeals or Medicare DME or Medicare LCD list of non-covered part highlighted or marked
    • Letter of medical necessity from one of the following: doctor, physical therapist, occupational therapist or seating therapist

     

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  • Client AGREEMENT

    This section must be completed by the client/individual that this request is for. An email will be sent requesting signature to the email address listed above in the client section.
  • CERTIFICATION AND ACCEPTANCE: I certify that information contained herein is true and complete and accept the obligation to comply with the terms and conditions if the request is awarded as a result of this application. Non-Discrimination: The Permobil Foundation will not make contributions that discriminate on the basis of race, color, religion, gender, mental or physical disabilities, sexual orientation, national origin, age, citizenship, veteran/reserve/national guard status or other protected status; partisan political organization; or groups limited to members of a single religious organization.

  • PUBLICITY WAIVER AND RELEASE AGREEMENT:

  • I hereby irrevocably permit, authorize and license to Permobil Foundation and its licensees, assigns, successors, parent company, subsidiaries, owners, operators, and other affiliates, and each of the respective officers, directors, employees, shareholders, contractors, agents, associates, and representatives, (collectively “Assignees”), the universal, unrestricted and perpetual right to use my name, image, likeness, voice and/or appearance as such may be embodied or recorded in any photos, video recordings, audiotapes, digital images, or any similar medium, (collectively “Information” I understand this waiver and release signifies that the Information described herein may be electronically displayed via the Internet or via any other medium with no time limit on or geographic limitation to which these materials may be distributed. By signing the in-kind product application and/or sponsorship application, I hereby waive any right that I may have to inspect and/or approve the finished works or the use(s) of the Information. I further hereby release, discharge and agree to hold harmless Assignees from any liability, any claim or cause of action, whether now known or unknown, for defamation, invasion of privacy, publicity or personality or any similar matter, or based upon or relating to the use and exploitation of the Information. PARENTS OR GUARDIANS OF CHILDREN UNDER AGE 18 MUST SIGN THIS RELEASE: I am the parent or guardian of the minor named above. I hereby make and enter into each and every representation, license and assignment described above on behalf of me, the minor, and any other parent or guardian of the minor. I believe and represent that I have legal authority to make these representations, grant this license and assign the Information to Assignees, and I agree to indemnify Assignees for all liability arising out of any lack of authority on my part to make such representations.

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  • DEALER/VENDOR AGREEMENT

    This section must be completed by the wheelchair dealer/vendor. An email will be sent to the email address listed above in the dealer section.
  • Before the Foundation Board of Directors will review this request, we require all parties be aware that the Foundation cannot assist with future repairs to the product/chair that is being requested. Meaning if the Foundation Board of Directors approves to donate the requested item(s) and if for some reason a repair is needed on this chair the financial obligation and service of the repair is between the client and the dealer. By signing below, you agree to handle future repairs and services with the client and that the Foundation is not liable or responsible.

    Please note that if you order the chair prior to the board’s decision on this request we CANNOT assist with any upgrades or financial support after the chair has been ordered, therefore hold on ordering until you are notified as no credits will be issued.

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  • Thank you for applying.

    Please read instructions below and then click submit button.
  • All requests are due by the 20th of each month

    • If you are the client: an email about your request will be sent to your dealer/vendor that you listed in this application requesting approval and signature. Once that is complete we can begin processing your request for review.
    • If you are the dealer/vendor: an email about this request will be sent to the client listed in above application requesting their signature. Once complete we can begin processing this request for review. 
    • For more information please visit our website: www.permobilfoundation.org or email us here: info@permobilfoundation.org
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