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