APPLY NOW

REVIEW PROCESS
& CONDITIONS

*Please review our conditions and disclosures.

Each application will be reviewed by committee members

Applications are reviewed weekly

We may contact the applicant’s healthcare providers for additional information if needed

Applicants will be notified once a decision is made

Money will be provided directly to the equipment vendor or service provider

We may utilize social media, e.g. Facebook, to inform our donors how funds are being allocated

Private information will not be revealed

APPLICATION FOR ASSISTANCE

Applicant's Name *

First

Last

Date *

List items & anticipated costs you are seeking financial assistance for (i.e. wheelchair, walker, cane, braces, ramp, home modifications): *

Tell us how this equipment will help you improve independence or quality of life:

Have you already sought other resources (insurance, charity, government assistance programs, etc.) to pay for the requested items? Please list: *

Please provide a detailed history of your medical condition/injury that led you to request financial assistance: *

How much money can you contribute for the cost of the item(s)? *

Physician's Address

Physician's Name *

First

Last

Physicians Phone Number *

Therapist's Name *

First

Last

Therapist's Phone Number *

Case Manager's Name *

First

Last

Case Manager's Phone Number *

Applicant's Address *

Applicant's Phone Number *

Applicant's Email *

What is your preferred method of communication? *

Phone
Email

If someone is helping the applicant complete this form on their behalf, please provide name and phone number. *

I attest that the information provided is accurate to the best of my knowledge and agree to the conditions listed above. *

Website

DISCLOSURE

This is a charitable organization not subject to rigors of HIPAA Compliance or enforcement. MOBL Charity takes every precaution to maintain the confidentiality of your records. Email is the most efficient way for us to gather information and access your situation as a team. This is a disclosure and your consent to allow email communication with PHI (protected health information) and PPI (protected personal information) which includes medical, personal and financial information.

MOBL Charity may follow up by phone or email for follow up information from applicant.

PRINTABLE APPLICATION

If you prefer to print our application instead of fill it out online, simply download the PDF, fill it out at your convenience, and email it to us when completed.

REVIEW PROCESS & CONDITIONS

APPLICATION FOR ASSISTANCE

DISCLOSURE

PRINTABLE APPLICATION

REVIEW PROCESS
& CONDITIONS