top of page
Center for Independence
Empowering Individuals with Disabilities since 1982
MENU
CFIGJ
Close
Donate
Resources
About Us
VCP
Deaf and Hard of Hearing
Ticket to Work
Transition Services
DME
Contact Us
Apply for Services
General Application
Disability Benefits Application
ASL Request
Job Applications
Calendar
Durable Medical Equipment Request Form
Today's Date
First name of Individual in Need
Last name of Individual in Need
Email
Phone
Address
What Durable Medical Equipment are you requesting? Do you need a special size? (i.e tall walker, large seat, Bariatric Bead, etc)
When do you need it by?
Month
Day
Year
Who will pick up the DME Items?
Submit
bottom of page
