Get Marilyn Westbrook Garment Fund

The Marilyn Westbrook Garment Fund application is designed to assist individuals who require lymphedema garments but face financial barriers. This guide provides clear instructions to help you complete the application efficiently and accurately.

Follow the steps to complete your application successfully.

1. Press the ‘Get Form’ button to access the Marilyn Westbrook Garment Fund application form and open it in your preferred editor.
2. Begin by filling out the cover sheet. Provide your NLN member number, name, contact details, and specify if the patient is a minor by including the guardian's name.
3. Complete the application checklist section. Ensure you include a prescription covering the necessary details, such as garment style and compression class, along with any relevant Explanation of Benefits or insurance denial documents.
4. In the financial need section, accurately disclose your annual household income and provide details about all family members supported by this income. Indicate whether the income is generated from one individual or a joint source.
5. Fill out the health insurance information. Answer the questions regarding your coverage, deductible, co-payments, and type of health insurance.
6. Detail your medical history as requested. Include your year of birth, type of lymphedema, cause, and any relevant information regarding your current use of compression garments.
7. Have your therapist or physician complete the Medical Necessity Form. Ensure they describe the severity of your condition and confirm the required garment specifications.
8. Review your application to ensure all fields are adequately completed. Ensure all required documents are attached before submitting.
9. Finally, save your changes and download, print, or share the completed application form as needed.

Start your application for the Marilyn Westbrook Garment Fund online today!