What's Needed for an Application?
- CSN Fund Application (Form DCH-1239)
- Letter from the family explaining the need and reason for the request
- Letter of medical necessity from the child's specialist explaining the need for the requested item
- Documentation of Assistance (Form DCH-2423)
- Bids/quotes for the item (see table on page 2 of the application)
Additional Required Items (if applicable)
- Financial Assessment (Form DCH-1273) ~ ONLY if the child is not enrolled in CSHCS
- Landlord Agreement (Form DCH-2424) ~ ONLY for wheelchair ramp or electrical upgrade on rental property
- Rifton (or AMTRYKE) order form completed by OT/PT ~ ONLY if requesting a Rifton or AMTRYKE