2020 Application for Assistance

To Qualify YOU MUST:

Include a letter or prescription from the applicant’s doctor confirming the need for the requested assistive device or therapy.
Include a copy of parent(s)/guardian(s) most recent Income Tax Return (IRS Form 1040) with copies of all supporting W-2 forms. For your security all information is confidential and treated with the utmost sensitivity. Please black out your social security number. All documents will be shredded once a decision has been made.
Include a letter of denial from parent(s)/guardian(s)
insurance company.
Live within Arizona

Please be advised that the Suzy Foundation will directly purchase the assistive device or therapy for the applicant. Suzy Foundation will NOT reimburse services rendered or devices previously purchased. Please include all of the necessary purchasing information. Please use the form below to apply for Suzy Foundation assistance. Once you complete the form, you can upload your application files here. Please label your folder with YourName_Date and zip all files before you upload. If you need technical assistance please call us or send us an email.

Please label your files with the name of the Applicant and the Document Name : Example – prescription would be labeled: ApplicantName_Prescription.doc

Applicant’s Name

Today’s Date

Name of Person Completing the Form

Email Address

Phone Number

Relationship to Applicant

Applicant’s Date of Birth

Describe/List Applicant’s Medical Condition

Please explain how this condition affects the applicant

What medical device or therapy are you requesting?

What is the cost of the medical device or therapy?

Please provide purchasing information for this device or therapy

Is the applicant currently receiving any of the following services?

*If the applicant is not receiving any of the above service(s) have you applied?

If yes, what was the outcome of your application?

Is your child currently receiving any of the following therapies?

*If the applicant receives OT, PT, or speech therapy, and the device or service you are requesting will improve his or her progress within that therapy: Please attach a letter from the applicant’s therapist detailing your child’s current limitations and progress.

Have you attempted to obtain this device through insurance?

If yes, what was the outcome?

**If not covered by your insurance, please attach an official letter of denial from
your insurance provider at the end where you upload files.

What benefit(s) would the medical device provide for the individual?

Use the space below, to add any additional information you wish to share with us in support of your application

If selected, may Suzy Foundation use the applicant’s photo and story to help market and promote the good work we do?

How did you hear about us?

Person to Contact if Selected

Parents/Guardians Name

Home Address

Phone Number

Preferred Method of Contact

2020 Application for Assistance

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