Download the application here or fill it out online below: Application for Durable Medical Equipment Authorization to Pick Up Donated Equipment Authorization to Deliver Durable Medical Equipment Saving Our Seniors Applications For Equipment Fields marked with an * are required Have you tried to obtain Durable Medical Equipment (DME) through other sourcesYesNoWhy were you unable to obtain the Durable Medical Equipment (DME) ?Medicare/Insurance DenialFinancial LimitationsMedicare 5 Year RuleDate of Application Date Format: MM slash DD slash YYYY Name*Birth Date*Address* Address City State Phone NumberMonthly Income*Height and Weight*Email* Durable Medical Equipment (DME) request - Brief DescriptionThe Equipment will be used for me or my family member's personal use and will not be sold to all the best of my knowledge all the information is true and accurate. I understand that based on my monthly income a donation will be requested upon delivery. Yes No Signature BoxCommentsThis field is for validation purposes and should be left unchanged. Volunteers Our organization encourages the participation of volunteers who support our mission. If you agree with our mission and are willing to be interviewed and trained in our procedures, we encourage you to complete this application. The information on this form will be kept confidential and will help us find the most satisfying and appropriate volunteer opportunity for you. Thank you for your interest in our organization Name:*Address: Address: City: State: Zip: Phone:*Email:* Employer:Position:Circle which areas you are interested in volunteering: Administration Events Program Fundraising Deliveries Communication Please circle days available: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Any Physical limiations:As a volunteer of our organization I agree to abide by the policies and procedures. I understand that I will be volunteering at my own risk and that the organization, its employees and affiliates, cannot assume any responsibility for any liability for any accident, injury or health problem which may arise from any volunteer work I perform for the organization. I agree that all the work I do is on a volunteer basis and I am not eligible to receive any monetary payment or reward.Signature:Date: Date Format: MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Saving Our Seniors In the News View Media Page & Videos
