To request equipment worth over $200, use this form. If your requested equipment is worth less, use the short form.
If you’d rather mail us your application, you can download this printable version.
In addition to the form below, we will need:
- a letter from your healthcare provider with the relevant diagnosis, specific request for funding, and any other important information
- proof of income (pay stub, last year’s 1040 or W-2, or a letter from employer).
You can email this information to email@example.com or fax to 406-797-5008.
Thanks for applying! We can’t wait to work with you.