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You may save this application and return at any time. Please note that applications will not be reviewed until they are submitted. Submitted applications are reviewed within five business days approximately. Applications are not considered complete until all required documents have been received by MDA.

MDA Membership:
All applicants must be a member of MDA to apply for the MDA DME Grant. I understand that by submitting this form, I/my family will automatically be registered with MDA. There is no fee associated with your MDA membership. Becoming a member is free, easy, and a great way to stay up to date on clinical care, research, access to treatments, events, in-person and online programming and more. For more information or to complete the membership information on your own, visit https://www.mda.org/join-mda.

Items you may need to support your application:
  • Register as a member of MDA at mda.org/join-mda.
  • Letter of medical necessity or prescription from a health care professional.
  • Vendor contact information.
  • Quote & W9 from your vendor of choice. If you do not have one in mind, we can suggest options. You are not required to use a vendor provided by MDA.
  • Additional funding source documentation.
Acronym library:
ADL - Activities of daily living
DME - Durable Medical Equipment
EOB - Explanation of Benefits
LMN - Letter of Medical Necessity
MDA - Muscular Dystrophy Association
NMD - Neuromuscular disease

Person with neuromuscular disease (NMD):













Best Contact Person (if someone other than person with NMD)
For minors, this must be a parent or guardian.















Documents

You must have a quote or invoice at the time of application. If you do not have this and need help identifying a vendor, please reach out to MDA at ResourceCenter@mdausa.org or call (800) 572-1717, option 1.






Responses in this section will not affect eligibility. This information is used for reporting and to help us identify gaps in access to equipment. While required to answer, you may select "Prefer not to answer" for some of the questions in this section.
















Certificate & Release Section
Please review the items below and sign or type your name and date to indicate that you have read and agree to the following:
  • I understand that the MDA DME Grant is not guaranteed upon application and will be reviewed by an MDA Specialist.
  •  I understand that if granted, the MDA DME Grant may not be able to fulfill the entire requested amount. Before payment, full funding commitment must be secured.
  •  MDA is not able to reimburse or approve already purchased Durable Medical Equipment. MDA will only pay a third-party vendor. MDA does not choose the vendor or show preference.
  • I agree to MDA's terms and conditions and privacy policy. Please visit www.mda.org/about-mda-privacy-policy for more information.
  • I certify I am a US citizen or a legal and permanent resident of the US.
  • I certify that I have been diagnosed by a physician with a neuromuscular disease supported by MDA. For more information, please visit www.mda.org/disease/list.
  •  I understand that all applicants must be a member of MDA to be considered in the MDA Grant Program. By completing this form, you/your family will automatically be registered with MDA. There is no fee associated with your MDA membership. For more information, please visit www.mda.org/join-mda.
  • I give permission to MDA to verify and/or confirm any information provided in this application, and I authorize release of that information for the purposes of application evaluation.
  •  I understand and accept that my personal data will be collected as a result of my submitted application for the MDA DME Grant Program and may be used for future MDA communications.
  • I certify that the information provided in my application is, to the best of my knowledge, complete and accurate.
  • I understand that false statements on this application will disqualify me from receiving an MDA DME Grant award.
  • I understand that it is my responsibility to ensure that all applicable supporting documents and requests are received by MDA by the given deadline.
  • I (my child), on behalf of myself, my family members, heirs, personal representatives, and assigns (the "Releasing Parties"), do hereby release, waive, and discharge MDA, its directors, officers, employees, volunteers, chapters, licensees, cooperating entities, agencies, representatives, heirs, executors, administrators, successors, and assigns (the "Protected Parties") from liability arising from injury or damage that may occur while using equipment associated with MDA's DME Grant.
  • I understand MDA is not the owner of DME received with the assistance of MDA's DME Grant Program.
  • If awarded, I understand the MDA DME Grant award is for personal use.
  • I understand MDA cannot facilitate returns, exchanges, replacement, or repair for equipment purchased with the MDA Grant.
  • I confirm that I am 18+ years old or a parent or guardian completed this application on behalf of the applicant.
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