• Purpose
• General Information
• Funding Information
• Application Considerations
• Application Process
• Items Typically Funded
• Other Considerations
• Contact Information

• Application must be completed and signed by the applicant.
• Financial information must be listed for each person in the dwelling in which the applicant resides.
• Physician's prescription is required for all items needed.
• If total cost of items is $200 or less, only one (1) price quote is required.
• If total cost of items is over $200, two (2) price quotes are required.
• Hearing aids require only one price quote.
• If there are extenuating circumstances, a short letter may be included but is not required.
• Mail or fax application, prescription, and quote(s) to address or fax number listed at bottom of application.

   (Click printer icon to download application in PDF format)

Application Process:
 

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