Please Deliver (delivery form as a form to this page) Deliver_Form.pdf Application For Saving Our Seniors Date of Application MM slash DD slash YYYY Why were you unable to obtain the Durable Medical Equipment (DME) ?Medicare/Insurance DenialFinancial LimitationsMedicare 5 Year RuleName* What type of insurance do you have?* Birth Date* Address* Address City State Phone Number* Monthly Income* Height and Weight* Email* Durable Medical Equipment (DME) request - Brief DescriptionThe Equipment will be used for me or my family member's personal use and will not be sold to all the best of my knowledge all the information is true and accurate. I understand that based on my monthly income a donation will be requested upon delivery. Yes No Signature Box[anr-captcha]PhoneThis field is for validation purposes and should be left unchanged.
