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