Application


If you or someone you know is 20 years old or younger and needs assistance obtaining medical equipment or services that is not covered by insurance, please contact us via the form below to request an application.

At this time, we are accepting applications from applicants living in Oregon, Washington, Idaho and California. Check back to see when we extend our geographic reach. 

Please follow the instructions on the application and complete in its entirety, mail it to us by US mail and we will review your need.

Please note: We do not pay deductibles or co-pays on insurance. At this time we will not purchase iPads, iPhones, computers, tandem bikes, vehicle or home modifications.