Quality of Life Equipment Grants

Transcription

1 Quality f Life Equipment Grants Abut the Quality f Life Equipment Grants Prgram The MS Sciety f Canada makes available t individuals living with multiple sclersis (MS) a Quality f Life Equipment Grants prgram. Quality f Life grants will supprt the purchase f the belw types f equipment, which must be new unless they have been recycled and certified by a licensed equipment vendr. Funding fr ther types f equipment is cnsidered in terms f the equipment s direct, psitive impact n the applicant s quality f life and MS symptms. Please cntact the MS Sciety if yu are unsure if the equipment fr which yu wuld like funding fr is eligible. Bath aids (bath lifts, bath chairs, bath benches, and handheld shwers) Braces and supprts (rthtics, leg braces, and splints) Brda chairs CEP cmputer leases Cmmdes Cmputers with adaptatins Electric hspital beds and mattresses Envirnmental cntrls (central air and prtable air cnditiners) Mbility aid equipment repairs (batteries and tires) MS-related eye glasses, dental, and hearing aids Flr t ceiling transfer ples Grab bars Hme accessibility equipment (prch lifts, autmatic dr peners, stair glides, and ramps) Kitchen aids (aut feeders and utensils) Lift chairs Lift systems (ramp installatins and repairs) Manual wheelchairs (tilt and nn-tilt) Pwer wheelchairs (tilt and nn-tilt) Prescribed rthpedic shes and bts Raised tilet seats, tilet safety frames, and versa frames Scters (three- r fur-wheel) Transfer disks, belts, and bards Trapeze bars Vehicle adaptatins (lifts, hand cntrls, and left ft acceleratrs) The maximum amunt f funding is $1,000/applicant. Applicants may nly submit ne applicatin per calendar year; hwever, it may cntain requests fr funding fr multiple pieces f equipment. The MS Sciety f Canada is unable t prvide nging financial assistance, meaning requests are fr ne-time equipment funding nly. Quality f Life grants are unable t supprt retractive requests and cannt be put twards the cst f equipment that has already been rdered r paid fr. Quality f Life grants will nt duplicate existing funding prgrams, but can be used t supplement ther funding. Befre applying fr a Quality f Life grant, individuals must first Revised 03/29/2018 1

2 apply t and receive apprval r denial frm ther funding surces [e.g., Assured Incme fr the Severely Handicapped (AISH), Alberta Easter Seals, Alberta Aids t Daily Living (AADL), Ceridian Cares, lcal funding surces, etc.]. Applicatin Eligibility 1. An applicant s physician r nurse practitiner must prvide a letter cnfirming the applicant s diagnsis f MS. 2. T be eligible fr funding, an applicant must reside in Alberta r the Nrthwest Territries r be supprted by the Llydminster Chapter. 3. Applicants must submit a letter frm an apprpriate healthcare prfessinal (e.g., ccupatinal therapist, physitherapist, etc.) explaining hw the equipment fr which they are requesting funding will enhance the applicant s quality f life and MS symptms. 4. The applicant r their designate must submit a cmplete cpy f this applicatin, including qutes, and shwing that ther ptential funding surces have either apprved r denied their request. Applicants must be willing t wrk with a health prfessinal and the MS Sciety t research all available funding surces. 5. If requested, the applicant will need t demnstrate that there is a financial need fr funding. The applicant r their designate must sign the related Declaratin f Financial Need. 6. Criteria cnsidered in the decisin-making prcess includes, but is nt limited t, the type f request, the submitted qutes, available resurces, and financial need. 7. If the applicatin is apprved, applicants must use their funding within 3 mnths f receiving their apprval letter. If the funding is nt used within 3 mnths, the applicant must submit a new Quality f Life applicatin, including updated qutes. 8. Althugh all attempts are made t purchase the applicant s first chice f equipment and use their preferred vendr, it may be necessary t substitute equipment r vendr based n, but nt limited t, equipment availability and cst. 9. Applying des nt guarantee that the applicant will receive funding. Funding is limited and is prvided t persns with MS wh demnstrate extrardinary financial need, as indicated in pint 5 abve. Hw t Apply Ensure that yur request meets the abve applicatin criteria. Fill ut the attached Quality f Life Grants Applicatin. Cnfirm that all paper wrk is cmplete, and that the request meets the abve applicatin criteria - if yu are unsure, please use the infrmatin at the end f the applicatin t cntact the MS Sciety. Revised 03/29/2018 2

3 Ensure that the applicatin includes tw written qutes fr the equipment fr which funding is being requested. Ensure that the applicatin includes written cnfirmatin f yur MS diagnsis (frm a physician r nurse practitiner). Ensure that the applicatin includes a written explanatin f hw the equipment fr which yu are requesting funding will enhance yur quality f life and MS symptms (frm an apprpriate healthcare prfessinal). Prvide prf f acceptance r denial frm ther surces f funding [e.g., Assured Incme fr the Severely Handicapped (AISH), Alberta Easter Seals, Alberta Aids t Daily Living (AADL), Ceridian Cares, lcal funding surces, etc.]. Sign the Applicatin Declaratin and the Declaratin f Financial Need. Submit the applicatin t yur lcal MS Sciety f Canada Chapter r Reginal Office. Incmplete applicatins cannt be reviewed and will be returned t the applicant r their designate. Remember that the MS Sciety reserves the right t request further dcumentatin. Applicatin Review 1. A cmmittee reviews submitted applicatins. Pending unfreseen circumstances, the cmmittee members will either apprve r deny a request fr funding within 3-4 weeks f receiving the fully cmpleted applicatin. 2. Once the reviewing cmmittee has apprved r denied an applicatin, a letter is mailed t the applicant r their designate t ntify them f this decisin and next steps. 3. If the equipment supplier will nt directly bill the MS Sciety, applicants shuld cntact their lcal MS Sciety f Canada Chapter r Reginal Office t ask if ther payment arrangements can be made. 4. Funding MUST be apprved in advance f the equipment rder r purchase. Once the MS Sciety has prcessed payment r the applicant has received their equipment, the funding case is clsed and n returns, changes r exchanges can be made. Revised 03/29/2018 3

4 Quality f Life Equipment Applicatin Frm NOTE: Please fill ut all sectins f the applicatin, as incmplete applicatins cannt be reviewed and will be returned t the applicant r their designate. Applicant Infrmatin Name: Address: City: Prvince: Pstal Cde: Phne: (w) (h) (c) Are yu a current MS Sciety f Canada member? Yes: N: Please indicate if yu are receiving incme supprt and, if s, the nature f it [e.g., insurance benefits, Canadian Pensin Plan Disability benefits, Assured Incme fr the Severely Handicapped (AISH), etc.] Revised 03/29/2018 4

5 Funding Request Describe the equipment fr which yu are requesting funding (i.e. what are yu asking fr?). Indicate the funding surces that yu have applied t and if yur applicatin t them was apprved r denied. Please cmment n the applicatin status r why funding was denied. Apprved Denied Cmments (i.e., applicatin status, reasn fr denial, etc.) Alberta Aids t Daily Living Alberta Easter Seals Assured Incme fr the Severely Handicapped (AISH) Residential Access Mdificatin Prgram (RAMP) Ceridian Cares Other Revised 03/29/2018 5

6 Funding Request Breakdwn Prvide a financial breakdwn f all the surces f funding that will be used t supprt the purchase f the equipment. Equipment Cst (Ttal) Applicant Cntributin Cntributins frm Other Surces MS Sciety Cntributin Ttal (All Cntributins) If yu cannt cntribute t the purchase f the equipment (i.e. Applicant Cntributin = $0.00), please explain why. Vendr Infrmatin Frm what suppliers have yu requested qutes? Please indicate yur preferred supplier Have the tw supplier qutes been attached t yur applicatin? Yes: N: Revised 03/29/2018 6

7 Quality f Life Impact If yur Quality f Life applicatin is apprved, hw will this equipment imprve yur quality f life and experience f MS? If the MS Sciety can nly prvide a prtin f the funding requested, what impact wuld this have? Supprting Dcumentatin Have yu attached the apprpriate supprting dcumentatin? 1. Letter frm physician r nurse practitiner cnfirming MS diagnsis. 2. Assessment r letter f supprt frm an apprpriate healthcare prfessinal explaining hw the equipment fr which yu are requesting funding will enhance yur quality f life and MS symptms. Yes: Yes: N: N: 3. Apprval r denial letters frm ther funding surces. Yes: N: Revised 03/29/2018 7

8 Applicatin Declaratin I,, give permissin fr the Prgrams & Services Staff at the MS Sciety f Canada t cnsult with health prfessinals r financial benefits wrkers invlved in assessing r cnfirming this request fr funding. I certify the statements made by me in this applicatin are true and cmplete t the best f my knwledge. I understand that if any f these statements are fund t be untrue, this applicatin will be rejected. Signature f Applicant r Designate Date Declaratin f Financial Need I understand that the MS Sciety f Canada prvides n-cst services and prducts (supprts) t thse affected by MS wh wuld therwise be unable, due t financial hardship, t affrd thse supprts n their wn. I cnfirm that I am applying fr financial supprt thrugh the Quality f Life Grant Equipment Prgram. I als cnfirm that, withut the assistance f the MS Sciety f Canada, I wuld nt be able t btain these supprts based n my wn financial means. I als understand that I may be required t prvide additinal infrmatin n my financial status with regards t my applicatin fr a Quality f Life (Q f L) Grant. Name Signature f Applicant r Designate Date Revised 03/29/2018 8

9 MS Sciety f Canada Privacy Plicy The Multiple Sclersis Sciety f Canada prtects clients privacy. The infrmatin cllected is used t prvide services t clients, cmpile mailing lists fr newsletters, infrmatin abut prgrams and meetings and t cmpile annymus statistical infrmatin. It is shared with authrized individuals and cmpanies utside the MS Sciety f Canada nly if a Release f Infrmatin Frm is signed by the client. By cmpleting this frm, yu hereby cnsent t the cllectin, use and disclsure by the MS Sciety f yur persnal infrmatin in accrdance with the MS Sciety privacy plicy. If yu have any questins abut yur persnal infrmatin, please cntact yur lcal MS Sciety Office at A cpy f ur privacy plicy may be btained at any MS Sciety ffice by calling r at Fr ffice use nly: Apprved Denied Amunt Date: Ntes: Revised 03/29/2018 9