Wayman L. Tisdale Foundation Inc. Application for Funding Assistance

Mission

Our Mission is to work with other organizations to identify individuals with prosthetic needs but with limited personal resources for cutting-edge prosthetic care. Realizing more than 156,000 people in the United States will experience the loss of a limb; we are committed to becoming a funding source and a resource for those in need. Our goal is to improve the lives of our recipients one person and one family at a time. We know we can make a difference.

Application Criteria

⦁ Must fill out the application in its entirety.

⦁ Must be able to wear/operate a prosthetic device.

⦁ All information submitted in an application is strictly confidential. It will only be used for the sole purpose of the selection process.

⦁ All forms must be completed, signed, and dated. Applications with blanks or missing critical information could be eliminated from the selection process.

⦁ Upon review of all documents, WLTF may request additional information and documentation.

⦁ The application and prosthetic service provider selection will be made by the Wayman L. Tisdale Inc., Board of Trustees. The decision will be final.

Required Documentation

⦁ A description in your own words of your situation and why you need financial assistance.

⦁ Explanation of the denial from your primary and/or secondary insurance carrier

⦁ Explanation of all other funding sources that you have requested funding from, including reason for denial of funding from each.

⦁ Photos: full front, full back, residual limb

⦁ Photo / Video Release Form

Guidelines

⦁ It is the goal of the board to provide prosthetic limbs to a minimum of two (2) individuals per year.

⦁ An application must be submitted to the Wayman Tisdale Foundation, Inc., Board of Trustees, to receive funding for a prosthetic limb

⦁ The submission deadline date is May 1st, of each year.

⦁ The board will select the recipient(s) at the June board meeting.

⦁ The Wayman Tisdale Foundation, Inc. will provide an adult with one (1) adult prosthetic limb per lifetime.

⦁ The Wayman L. Tisdale Foundation will provide a child multiple prosthetics limb as they grow with a $10,000 lifetime maximum.

⦁ The recipient will receive funding for the prosthetic limb as well as the physical therapy and routine maintenance for the life of that prosthetic limb.

⦁ The recipient may be asked to be featured in publications such as our fund-raising brochure.

⦁ The recipient must be an Oklahoma resident.

⦁ You’ll receive a notification from the Executive Director by July 15, whether your application has been approved.

Prosthetic Application

APPLICANT INFORMATION

First Name

Phone

Date of Birth

Last Name

Address

PARENT OR GUARDIAN INFORMATION

First Name

Last Name

Phone

Address

Do you currently have a prosthetic?

Yes

Name of your Primary Care Physican

Do you have medical insurance?

Yes

Please list the type of prosthetic limb needed:

Have you been denied from your primary and/or secondary insurance provider?

Yes

Please explain the denial reason from your primary and/or secondary insurance carrier.

Did you request funding from other sources? *

Yes

If you said yes to requesting funding from other sources, please list the name(s):

Please explain why you need financial assistance. The explanation should include reason(s) for denials by your insurance or other funding sources.

Photo & Video Release Form:

By signing this form I give my consent to Wayman L. Tisdale Foundation, Inc. to use any photographs, video, or any other medium taken of me for educational and/or publication purposes.

Your Signature

Select Today's Date

Thank you for your application. We will contact you soon!