APPLICATION FOR BARBARA PIERCE-NORD FUND
FOR ASSISTIVE EQUIPMENT
The Barbara Pierce-Nord Fund was established in 1994 to assist individuals with arthritis,
rheumatic diseases, and related musculoskeletal conditions, to improve their quality of life.
Barbara Pierce-Nord was a kind and giving person. She lived her life with the pain and
limitations of severe rheumatoid arthritis. But it did not slow her down. She could be spotted in
Sun City whizzing around on her electric scooter. One day in the grocery store someone asked
her about the motorized scooter and told Barbara just how lucky she was to able to afford the
luxury of mobility.
That encounter opened a new chapter in Barbara’s life. Soon after, she approached the Arthritis
Foundation with her thought of starting a fund for people who were less fortunate than she, and
the Barbara Pierce-Nord Fund was established to help people purchase equipment. Barbara
passed away in November 1993 and bequeathed the Arthritis Foundation a fund to help others
with demonstrated financial need. For this reason, it is necessary to provide basic financial
information, which will be kept confidential. The chapter also requires that each applicant have
a health care professional complete page 4 of the application form which states that the
requested item is necessary to improve the quality of life for the applicant.
Items covered under the program are Self-Help Devices and Assistive Equipment, which will
make life easier for people with arthritis.
Barbara Pierce-Nord’s kindness will live on through her fund.
There is a limited amount of funding per year
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BARBARA PIERCE-NORD FUND FOR ASSISTIVE EQUIPMENT
Please complete all information (pages 2 & 3) and return to:
Arthritis Foundation
5009 E. Washington St., Ste. 125
Phoenix, AZ 85034
Applicants will be notified within 30 days of the receipt of the application whether the request is
approved or denied. If the advisory committee has questions regarding your request, you may receive
a phone call or letter requesting further information, or an appointment for a site visit.
Name of Applicant:___________________________________________ Birthdate:_______________
Month
Day
Year
Street Address:______________________________________________________________________
City:_____________________________________ State:____________ Zip:____________________
Telephone Number:(_______)_________________________________________________________
Diagnosis (type of rheumatic disease):____________________________________________________
Length of Illness:
Months:________________________ Years:______________________________
Other medical disorders, conditions, surgeries:_____________________________________________
How did you learn about the Barbara Pierce-Nord Fund?_____________________________________
__________________________________________________________________________________
Requested Item:_____________________________________________________________________
__________________________________________________________________________________
Do you have assistance at home (i.e. care taker, spouse, etc.)? ________________________________
__________________________________________________________________________________
List other assistive devices, equipment, and/or devices you currently have:_______________________
__________________________________________________________________________________
Disclaimer: The information presented is true and accurate to the best of my knowledge
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CONFIDENTIAL
PLEASE ANSWER ALL QUESTIONS
FINANCIAL INFORMATION
INCOME (Monthly)
EXPENSES (Monthly)
Income
Social Security
Public Assistance
Other Family Members
$_____________
$_____________
$_____________
$_____________
Rent and/or Mortgage
Utilities
Food
Medications
Telephone
Other
$_______________
$_______________
$_______________
$_______________
$_______________
$_______________
TOTAL INCOME
$_____________
TOTAL EXPENSES
$_______________
Number of persons dependent on this income:_____________________________________________
Please attach proof of income
Applicant’s contribution to the cost:_____________________________________________________
Amount requested from the Arthritis Foundation:___________________________________________
MEDICAL INSURANCE INFORMATION
Health Insurance: Yes__________ No__________
If yes: Name of Insurance Company_______________________________________________
Policy Number__________________________________________________________
Insurance Telephone Number_______________________________________________
Name of Secondary Insurance Company______________________________________
Policy Number__________________________________________________________
Insurance Telephone Number_______________________________________________
Other Coverage:_____________________________________________________________________
__________________________________________________________________________________
Is the requested item covered by your insurance? Please explain:______________________________
__________________________________________________________________________________
Have you contacted any other agencies to assist with this request? If yes, Please list.______________
__________________________________________________________________________________
Are there any special circumstances which should be considered in this application?_______________
__________________________________________________________________________________
I realize that the Arthritis Foundation’s financial resources are limited and, therefore, I may be asked
to seek additional funding from other sources. I also certify the above information is true and
complete to the best of my knowledge.
Signature of Applicant:________________________________________Date:__________________
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PHYSICIAN RECOMMENDATION
FOR ASSISTIVE EQUIPMENT / SELF-HELP DEVICES
Please provide as much information as possible on the patient’s need for the requested item. Please
mention any special circumstances that should be considered.
Name of Patient:_____________________________________________________________________
Diagnosis: Specific kind of rheumatic disease:_____________________________________________
How long has patient had the condition? Months______________________Years_________________
Does the patient have specific physical limitations? Please list:________________________________
__________________________________________________________________________________
Requested Assistive Equipment:________________________________________________________
Please attach a prescription.
Please explain why the patient needs the item requested:_____________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Name (print):_____________________________________________Date:______________________
Signature:__________________________________________________________________________
Address: __________________________________________________________________________
__________________________________________________________________________________
Telephone:_(_______)________________________________________________________________
Hospital Affiliation: __________________________________________________________________
Disclaimer: The information presented is true and accurate to the best of my knowledge
PLEASE RETURN TO:
ARTHRITIS FOUNDATION
5009 E. Washington St., Suite 125
Phoenix, AZ 85034
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