Request Equipment - Devices 4 the Disabled

Formulario de solicitud de equipo

Effective September 1, 2024, all equipment requests must be from an approved Network Equipment Referral Partner of Devices 4 the Disabled.

Please read the following instructions carefully:

Complete this form fully and accurately to ensure the correct equipment is provided to the person in need without delays.
Click “Submit Request” at the bottom of this form to submit your request, and we will contact you to answer any questions.

Important Notes for Equipment Requests:

A letter of medical necessity (prescription) from an authorized healthcare provider (e.g., physician, physician assistant, nurse practitioner) is required for power equipment requests. Please submit this and any supporting documents with this Equipment Request Form to ensure timely processing.
Equipment Fittings & Pickup: We will contact the Recipient to arrange an appointment at Devices 4 the Disabled (Ed Kane Center) in Chicago for equipment pickup. Please provide two phone numbers for contact. If equipment fitting is required, the Recipient will need to be present for the appointment in our Seating & Mobility Clinic.
Inventory Availability: Devices 4 the Disabled offers a range of revitalized Durable Medical Equipment (DME) based on current inventory. If you need non-standard items or you do not see the equipment you need listed, please provide details in Section 3,”Additional Information,” so we can better assist in meeting the recipient’s needs.

Contact our support team by email at info@devices4thedisabled.org or call 773-870-1553 for assistance or with any questions.

SECTION 1: EQUIPMENT REFERRAL PARTNER INFORMATION

Equipment Referral Partner (Select from the list)

Referral Contact Person Information (Please provide the primary contact person for this referral.)

Referral Contact Person Phone

Phone Extension

Referral Contact Peson Email

Referral Partner/Institution Address

SECTION 2: RECIPIENT INFORMATION (Person Receiving the Equipment)

Recipient's First Name

Recipient's Last Name

Recipient's Email

Recipient's Phone Number

Alternate Phone Number to contact Recipient (Two Phone Numbers Must be Provided)

Address Line 1

Address Line 2

Ciudad

Estado

Zip Code

County

Date of Birth (MM/DD/YYYY)

Recipient's Diagnosis/Disability

Recipient's Height

Recipient's Weight

Recipient's Hip Width In Sitting Position (in inches) - Measure the distance across the widest part of the hips while the person is sitting.

Recipient's Primary Language Spoken

Additional Recipient Information

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Devices 4 The Disabled es una organización sin fines de lucro 501(c)(3).

EIN: 47-5180181

Teléfono: (773) 870-1553
Correo electrónico: info@Devices4TheDisabled.org

Centro Ed Kane: 2701 W. 36th Place, Chicago, IL 60632

Equipo distribuido por CITA SOLAMENTE los miércoles 10 AM – 3 PM.

Nunca daremos su información personal a nadie.