Bridge Abilities Equipment Request

Full name

Birthday

Month

Day

Year

Phone

Address

Primary Disability or Medical Condition

Do you have a doctor's recommendation for this equipment?

Yes

If yes, provide the doctor's name and contact information

Briefly describe how your disability affects your daily life

What type of equipment are you requesting? (Wheelchair, walker, hearing aid, etc.)

Why do you need this equipment?

Do you currently own or have access to similar equipment?

Yes

If yes, why is it not sufficient?

Have you applied for this type of equipment before?

Yes

If yes, what was the outcome?

Do you have health insurance that covers disability equipment?

Yes

If yes, why is insurance not covering this request?

What is your current income range? (Optional but helpful)

Are you receiving any government assistance? (Medicaid, SSI, SSDI, etc.)

Do you have any special requests or additional comments?