BEFORE YOU COMPLETE THIS APPLICATION FORM, PLEASE NOTE THE FOLLOWING:

  • Individuals with intellectual and developmental disabilities (I/DD) are eligible to receive critically or medically necessary equipment or services paid for by grant funds from the Community Health Outreach Project (CHOP). During 2023, only one application per household may be submitted, which is subject to a maximum allowance of $1,000.
  • You must provide the following documentation to accompany this application form:
    • A written notice from the Recipient’s physician indicating why the item/service requested in the application is critically or medically necessary for the Recipient.
    • Since payment will be made directly to its source, you must provide documentation validating your request. Examples include, but are not limited to:
        • An invoice from a physician office/clinic that requires payment for services rendered.
        • A complete description, including manufacturer, model number, and cost of the item/equipment to be purchased, along with where the item/equipment will be purchased (i.e., a printout from Amazon). CP State will order and pay for the item/equipment from the supplier and have it shipped directly to the Recipient’s residence

Click here for a print version of the application.

Click here for the application guidelines.

COMMUNITY HEALTH OUTREACH PROJECT 2023 INDIVIDUAL APPLICATION FORM FOR FUNDING ASSISTANCE

GENERAL INFORMATION ABOUT RECIPIENT

CP State shall not disclose or otherwise make available any personally-identifiable information or protected health information (PHI) in connection with this Application.
Recipient's Name
MM slash DD slash YYYY
Address
Gender
Ethnicity

Recipient has one or more of the following diagnoses: (check all that apply)

INSURANCE INFORMATION

Recipient is covered by the following insurance: (check all that apply)

GENERAL INFORMATION ABOUT CAREGIVER

Caregiver's Name

TOTAL HOUSEHOLD INFORMATION

Total Household Income
Please check the box that represents the Total Household Income, including work salary, SSI, SSD, child support, and all other income sources for all individuals living in the household. Household Income is defined as the combined gross income of all members of a household who are 15 years or older. Individuals do not have to be related in any way to be considered members of the same household.

FUNDING REQUEST

Examples: (a) Shower Chair. The manufacturer is Medline, and the model number is MDS89745RA. (b) Mental health evaluation as recommended by primary physician. Paperwork attached. (c) Hearing Aid. The manufacturer is AudioUS and the model is the Wave.
Since payment will be made directly to the source, you must attach an invoice or cost sheet (i.e., Amazon printout) detailing the item/service and the vendor to be paid.
Max. file size: 100 MB.
Examples: (a) Joe has trouble with his balance, and a shower chair will help in maintaining his independence while bathing. As a single mother, I prefer to allow him to shower alone. (b) Joe has had a change in his interest levels in his daily routine and is acting out in ways that current treatment options cannot address. The clinic where he is a patient would like a mental health specialist to evaluate him. I am concerned that his aggression will result in damage to the home. (c) Joe lost his left hearing aid and Medicaid will not pay for a new one for 3 years. He requires the hearing aid to maintain his ability to communicate properly with others.
Max. file size: 100 MB.
The CHOP Awards Committee will consider funding requests that are critically or medically necessary for the Recipient. You must attach a written letter of recommendation from the Recipient’s physician indicating why the requested item or service is absolutely necessary for the individual. Applications that do not include a physician’s recommendation are ineligible for funding.

REQUIRED – CONSENT TO RELEASE INFORMATION AND AFFIRMATION

Consent(Required)
Media Release

QUESTIONS? Email cmorris@cpstate.org or call Cindy Morris at 518-612-4510.