PERMOBIL FOUNDATION IN-KIND 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 #.
- If patient has Medicare and applying for assistance for a seat elevator then you must submit proof of denial or Explanation of Benefits (EOB).
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.
Person completing this form. *

I am the ClientI am Dealer/Wheelchair Vendor
CLIENT INFORMATION
Client Name

First NameLast Name
Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Email:
example@example.com
Client Phone Number

Area CodePhone Number
Client Age:
Client Diagnosis:
Do not list medical codes
Dealer/Wheelchair Vendor Information

IMPORTANT: Prior to submitting this application the DME Provider/Vendor/Dealer must have obtained a quote from Permobil and the wheelchair must not be ordered.
Name of DME Provider/Vendor/Dealer
EX: WheelchairsRUS
DME Provider/Vendor/Dealer Contact/ATP Name:
DME Provider/Vendor/Dealer Email:
example@example.com
DME Provider/Vendor/Dealer Phone #:
Please give phone # of the dealer listed above in case we have questions about application
Permobil Quote #:
Permobil Representative:
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)

*If you are applying for a seat elevator and client has Medicare you must submit copy of Explanation of Benefits (EOB) or other proof of denial.
At the bottom of this form you must also attach letter from doctor or physical therapist regarding the medical necessity of request.
1. What is client's primary insurance coverage (please check one):

Medicare (must upload copy of EOB or other proof of denial)MedicaidPrivate InsuranceCanadian Health Act
If private Insurance or Canadian Health Act please identify by name:
EX: BlueCross or Ontario Health Insurance
2. I verify all options to obtain Medicare and insurance and/or payment has been exhausted and I have documentation.*

YesNoN/A
3. What item(s)are being requested that were denied by client's primary insurance? (please list parts, not codes and list in priority of medical need)
4. Have all appeal options been denied by your primary insurance?

YesNo
5. Does client have secondary insurance?

YesNo
6. If the answer to question 4 is "YES", what items are being requested that were denied by secondary insurance?
STATEMENT OF NEED: We invite you to share a personal narrative explaining the unique impact this contribution will have on your life, aside from its medical benefits. Describe "the WHY" – the personal significance of this gift and its role in enhancing your autonomy. Please refrain from citing medically necessary reasons, daily living activities, or assistance with mobility or transfers. How will this gift contribute to your or the client's personal empowerment? EXAMPLE: I/Client will be able to elevate to height of fence at farm to feed his cows. EXAMPLE: I can reach my locker at school or elevate to participate in the choir at church. EXAMPLE: As an educator, the ability to stand while delivering lectures would be transformative for my teaching experience. EXAMPLE: It would grant me the honor of accompanying my daughter as she walks down the aisle on her wedding day.
Research Study: Client may be eligible to participate in future research studies. Would you like to be contacted?*

YESNo
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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 #
- Copy of insurance denials and appeals
- Explanation of Benefits or other proof of denial
- Letter of medical necessity from one of the following: doctor, physical therapist, occupational therapist or seating therapist
Letter of Medical Necessity from Doctor or Physical Therapist

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Insurance denial

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Explanation of Benefits or other proof of denial

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Client letter, Statement of Need or other documents

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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.
Client Signature

Clear
And/Or signature of person completing this form

Clear
Relationship to client:
Please type name/relationship to client. Your signature legally binds you to accepting this agreement on behalf of the named client above.
Date

MonthDayYear
Date
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.
Signature of Dealer

Clear
Date

MonthDayYear
Date
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
Should be Empty:

PERMOBIL FOUNDATION PRODUCT APPLICATION

CLIENT INFORMATION

Dealer/Wheelchair Vendor Information

INSURANCE INFORMATION

Upload your files below

Client AGREEMENT

PUBLICITY WAIVER AND RELEASE AGREEMENT:

DEALER/VENDOR AGREEMENT

Thank you for applying.