application

Application

F.R.E.E. is considered a provider of last resort and provides assistance only when all other resources are unavailable. Applications remain active for a thirty day period. Please note that a physician's prescription must accompany all applications.

If your request if for equipment valued at over $500.00, you are required to submit a "Letter of Medical Necessity" from your physician (a form is provided in this application). 

Click on the name of the chapter nearest to you to download the application. PLEASE NOTE - you can complete the form online but you must print the completed form and either mail it to the address on the form or scan the form and email it to the chapter email address. If you try to save the file, the information you have completed will not be saved: