March of Dimes HVMP Verification of Disability

Date of Birth

First Name

Last Name

Preferred Name (if different)

Marital Status

Pronouns

Mailing Address

City

Postal Code

What is the client’s disability?

What primary mobility device is used by the client?

How does the disability impact their daily mobility and result in substantial restrictions in activities of daily living (eating, bathing, toileting, transferring, and mobility) and/or getting in and out of their home to access essential medical care or community services?

What internal and external supports (people or services) does the client have to support their activities of daily living (eating, bathing, toileting, transferring, and mobility) and/or getting in and out of their home to access essential medical care or community services?

I have reviewed the clients request for modifications, adaptations, and devices and agree that it will help the client, check all that apply:

Applicant Information: (This is the person applying for funding for modifications adaptations and device)

Healthcare Professional’s Information (To contact you about your recommendations for modifications, adaptations and devices)