Application | VETTEK

APPLICATION FOR FINANCIAL ASSISTANCE

The person filling out the application must be 18 years or older.

Your Full Name

Contact Email

Contact Phone Number

Are You Applying on Behalf of Yourself or Someone Else?

Myself

Someone Else

Address of Recipient

Country/Region

Address

City

Zip / Postal code

Are you a United States Veteran, first responder, or dependent?

Veteran

First Responder

Dependent

Agency or Branch of Service:

Describe your service: Including component, service dates, job description, etc...

Describe your need for prosthetics or orthotics care, and financial assistance:

Please provide a brief paragraph detailing your financial need for this grant

Please attach one of the following to confirm eligibility: DD-124 (Redacted), Current Orders, VA Benefit Summary, Department ID, Commission Card, Retirement Credentials, or Proof of Sponsor's Service

Requested Funding Timeline:

All grant funds are disbursed exclusively to the healthcare facility for the provision of high-end prosthetic or orthodic technology. VetTek Foundation does not provide direct-to-consumer payments or individual reimbursements.

Clinical Facility Name:

Lead Clinician Name (CPO, CP, or CO):

Clinic Phone Number:

Clinic Email Address:

Please attach the following documents (provided by your clinician):

Itemized Quote

A formal quote on facility letterhead for the requested technology

Letter of Medical Necessity:

A brief statement from the clinician justifying the device

By submitting this application, I voluntarily provide VetTek Foundation with sensitive personal information, including service records and medical documentation.

I authorize the VetTek Foundation and its clinical review board to access, store, and review my protected health information (PHI) and service data for the purpose of evaluating grant eligibility.

I acknowledge that I have been advised to redact Social Security Numbers from all attachments

I certify that the information provided is accurate. I understand that the VetTek foundation provides high-end technology grants through a Direct-to-Provider model and that all approved funds will be sent directly to the clinical facility for my care.

I understand that someone from VetTek will reach out regarding the status of my application in approximately 7 to 10 business days. If my application is approved, they will review the next steps.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Month

Day

Year