Please answer all questions. If
the particular question does not apply to your child, use n/a. Please complete all sections and questions, providing us with
the necessary attachments; then, mail it to the address below.
SECTION I
Date_____________________________________
Child's Name_________________________________________________
Child's Date of Birth________________________
Child's Address____________________________________________________________________________
Telephone Number (including area code)_________________________
Name of Person Applying for Grant on Behalf
of Child, and their Relationship to Child
___________________________________________
Phone Number,
if different than Child's (in case we need to reach you for questions)_______________
How did you hear about
us?______________________________________________________________
Section II
Does your child
receive SSI? ( )yes or ( )no
Does your child receive Medicaid? (
)yes or ( )no
If yes, is medicaid the primary or secondary insurance? (
)Primary or ( )Secondary
If yes, is it a waiver program? ( )yes or (
)no
If yes, what type of waiver?_________________________
If yes, is it a HMO? ( )yes or (
)no
If it is a HMO, are you happy with them? ( )yes or ( )no
If you are not happy with your HMO, please explain.______________________________________________________________________
Does your child have any other health insurance? ( )yes or ( )no
If yes, are you satisfied with the service you are getting? ( )yes or (
)no
If you are not happy with your health insurance, please explain_____________________________________________________________
Does your child have school accident insurance? ( )yes or ( )no
Section III
Can your child walk unassisted? ( )yes or (
)no
Can your child walk assisted? ( )yes or ( )no
Can
your child crawl? ( )yes or ( )no
Can your child feed him/her self? (
)yes or ( )no
Can your child sit unsupported? ( )yes or (
)no
Can your child sit supported? ( )yes or ( )no
Can
your child assist with transfers? ( )yes or ( )no
Can your child
talk/communicate with others? ( )yes or ( )no
Does your child receive
physical therapy? ( )yes or ( )no
Does your child receive occupational
therapy? ( )yes or ( )no
Does your child receive speech therapy? (
)yes or ( )no
Does your child receive any other any other form of therapy? (
)yes or ( )no
If yes, please specify what kind_______________________________________
Has your child had surgery? ( )yes or ( )no
If yes, how
many?__________
Is your child on medication? ( )yes or ( )no
Does your child have any allergies? ( )yes or ( )no
Does
your child have seizures? ( )yes or ( )no
Has your child been diagnosed
with developmental delay? ( )yes or ( )no
Has your child been diagnosed
with autism? ( )yes or ( )no
Has your child been diagnosed with
mental retardation? ( )yes or ( )no
Has your child been diagnosed
with cerebral palsy? ( )yes or ( )no
Has your child been diagnosed
with down syndrome? ( )yes or ( )no
Has your child been diagnosed
with incontinence? ( )yes or ( )no
Has your child been diagnosed
with adhd? ( )yes or ( )no
Please list any other medical diagnoses
that your child has.___________________________________________________________
Does your child use pull-ups, diapers,
briefs, underpads, etc? ( )yes or ( )no
Does your insurance cover
the diapers? ( )yes or ( )no
If yes, what insurance covers the diapers?___________________________________________________
Does your child use a manual wheelchair? ( )yes or ( )no
Does
your child use a power wheelchair? ( )yes or ( )no
Does your child
use a gait trainer? ( )yes or ( )no
Does your child use a mobile
prone stander? ( )yes or ( )no
Does your child use a stationary
prone stander? ( )yes or ( )no
Does your child use a mobility stroller? (
)yes or ( )no
Does your child use afo's/hkafo's? ( )yes or (
)no
Does your child use a tens machine? ( )yes or ( )no
Does your child use a tes machine? ( )yes or ( )no
Does your child
use crutches? ( )yes or ( )no
Does your child use a specialized
car seat? ( )yes or ( )no
Does your child use a abductor wedge? (
)yes or ( )no
Does your child see a neurologist? ( )yes or (
)no
Does your child see a orthopedic surgeon? ( )yes or ( )no
Does your child see a pediatrician? ( )yes or ( )no
Does
your child see a gastrologist? ( )yes or ( )no
Does your child see
a neurosurgeon? ( )yes or ( )no
Does your child see a endocrinologist? (
)yes or ( )no
Does your child see a pulmonary doctor? ( )yes or (
)no
Does your child see a physical medicine and rehabilitation doctor? ( )yes or (
)no
Please list any other specialists that your child sees._______________________________________________________________
If your child is in a wheelchair, does he/she have a wheelchair ramp at home? ( )yes or (
)no
If your child is in a wheelchair, does he/she have a vehicle equipped with a wheelchair ramp? (
)yes or ( )no
If your child is in a wheelchair, is it handicapped accessible? (
)yes or ( )no
Does your child have an IEP? ( )yes or (
)no
Does your child receive respite? ( )yes or ( )no
Does your child receive nursing services? ( )yes or ( )no
What
equipment does your child currently need?
________________________________________________________________________
Do you foresee obtaining the above listed equipment from your health insurance? ( )yes or (
)no
Has your health insurance (whether primary or secondary) denied any equipment for your child?
(
)yes or ( )no
SECTION IV
What item(s) are you requesting a grant
for?________________________________________________________________
List the medical diagnosis that applies to
the item(s) requested._________________________
Do you have a certificate of medical necessity for the requested
item? ( )yes or ( )no
Do you have a quote for the item requested? (
)yes or ( )no
Do you have a letter of medical necessity for the item requested? (
)yes or ( )no
Do you have a evaluation for the item requested? (
)yes or ( )no
Do you have a denial from your insurance for the requested item? (
)yes or ( )no
Why are you requesting a grant from Snap4kids for the above item(s)?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
SECTION V
Would you like to receive our newsletter? ( )yes or (
)no
What is your email address?_____________________@_____________________________
Do you mind if
we send you email updates? ( )Please send updates or ( )Do NOT send updates
Have you ever visited our web site, at www.snap4kids.org? ( )yes or ( )no
Did you find it helpful? ( )yes or ( )no
Anything else you
want to add?___________________________________________________________________________________
______________________________________________________________________________________________________________
Mail
your grant request and the necessary documentation to: Snap4kids, 520 W. 21st Street, Unit G-2/706, Norfolk, VA 23517.
Please include a letter of medical necessity for the item being requested.
Please include a price sheet and/or order form for the item being requested.
Please send a photo of the child that the item is being requested for (photos
will not be used on our website.)
Remember,
the more medical documentation we have, the better.
Also,
if you have a denial from your insurance company, we need that too. Some items do not require a letter of denial (because
universally, all insurance companies do not cover particular items. However, with more insurance companies more items
to save money, if you do not attach a denial from your insurance company, then we must have a denial from your child's
doctor or therapist as to why the item is not covered under your health insurance plan(s).
If you are requesting assitive
technology then we need a copy of your evaluation.
Think of anything else that you'd like to add then just write
a letter and attach it to your grant request.
P.S. Have a nice day!!
