CycleMT Application for Funding

CycleMT Application for Funding

CRITERIA TO QUALIFY

Applicants must meet the following criteria to qualify for assistance:

Be 21 years old or younger at the time of submission
Live within the State of Montana
Have a health diagnosis that meets the mission of CycleMT
Meet Financial Eligibility requirements
Exhaust all Medicaid assistance options (if applicable)
Adhere to the maximum per year of requested funds. This includes the funding caps below.

FUNDING CAPS

Adhere to a maximum in requested funds and approved funding as listed below. This includes the following funding caps:

Maximum $5,000 in funding and/or three approved asks per year for Non-Covered Expenses (i.e. specialized equipment, non-traditional therapies, special programs, etc.).
$10,000 in a five-year period for vehicle modifications.
$10,000 in a five-year period for home modifications
If approved for a vehicle or home modification, you must wait until the following calendar year to apply for any additional funding for Non-Covered Expenses.

Financial Eligibility

The patient's or financial guarantor's taxable household income must be equal or less than 500% of the federal poverty guidelines (see table below)

2025 Federal

Family Size Poverty Level 500%

Individuals $15,650 $78,250

Family of 2 $21,150 $105,750

Family of 3 $26,650 $133,250

Family of 4 $32,150 $160,750

Family of 5 $37,650 $188,250

Family of 6 $43,150 $215,750

Family of 7 $48,650 $243,250

Family of 8 $54,150 $270,750

For a family of 9+ Add $5,500 for each additional person

Eligibility

These questions assist in determining your eligibility for this award.

Does your child have a medical hardship that is permanently affecting their everyday wellbeing?*

Yes

No

Home City and State:*

Is the applicant 21 years of age or younger at the time of submission?*

Yes

No

Do you meet the financial eligibility criteria listed above?*

Yes

No

Are you currently enrolled in one of the following waivers?*

Big Sky Waiver

Comprehensive waiver 0208 (developmental disability waiver)

Children's Autism Waiver

No, I am not on a waiver

If you do not qualify for one of the above waivers, are you willing to write a letter explaining your child's hardship and need for assistance and also have your doctor write a letter on your child's behalf?

Yes

No

The 2025 Application

Please complete the following sections. You will later be prompted to submit the accompanying required documentation.

Applicant Information
Parent/Guardian Information
Medical Information
Type of Request
Authorization of Disclosure of Medical Information
Marketing Release Form

*If you fail to submit all of the required documentations, your application will not be processed.

Applicant Information

First Name*

Middle Name

Last Name*

Date of Birth*

Street Address*

City*

State*

Zip*

County*

Parent/Guardian Information (if applicable)

First Name*

Last Name*

Is the Address the same as the applicant?*

Yes

No

Phone*

Phone

Email*

Best way to reach parent/guardian*

Medical Information

Patient's Diagnosis/Medical Eligibility*

Primary Provider*

If not applicable, please respond with N/A

Primary Clinic/Hospital*

If not applicable, please respond with N/A

Rehabilitation Provider*

If not applicable, please respond with N/A

Rehabilitation Clinic/Hospital*

If not applicable, please respond with N/A

Therapist*

If not applicable, please respond with N/A

Primary Health Insurance*

Secondary Health Insurance

Type of Request

NON-COVERED EXPENSES

$5,000 maximum per year for Non-Covered Expenses

Travel for Medical Appointments

Mileage will be reimbursed at $.65 per mile from city to city per Google Maps. Hotel per diem will be capped at $150 per night. Meals will be reimbursed at $100 per day (alcohol is not reimbursable)

You will need to submit:

Proof of appointment
Meal/Hotel receipts
Travel Worksheet (click link to download)

Equipment/Assistive Technology

You will need to submit:

CycleMT Letter of Support Form (click link to download)
EOB, Insurance Denial Letter or non-covered item list from insurance policy

Rehabilitation Therapies

You will need to submit:

CycleMT Letter of Support Form (click to download) from a provider within each area of practice (PT/OT/ST) dependent upon service area for which funds are being requested
Invoice clearly showing cost of service, which Logan Health will pay directly to program/company/service.

Non-Traditional Therapy

Massage
Hydrotherapy
Music Therapy
Biofeedback
Auditory Integration Training (AIT)
Therapeutic Recreation Therapy (horseback riding, etc.)
If another form of non-traditional therapy is being used, please include that information in the letter of support.

You will need to submit:

CycleMT Letter of Support Form (click to download) from a provider within each area of practice (PT/OT/ST) depended upon service area for which funds are being requested
Invoice clearly showing cost of service, which Logan Health will pay directly to program/company/service.

HOME ACCESSIBILITY MODIFICATION

$10,000 Maximum per five-year period

You will need to submit:

CycleMT Letter of Support Form (click to download) from a provider within each area of practice (PT/OT/ST) depended upon service area for which funds are being requested
If rental property, Letter of Support from the property owner

*Modification work must be under contract within one year of award notification

VEHICLE MODIFICATION

Consideration will be given for modifications made to vehicles for accessibility (ex. lifts, ramps, loading devices, tie downs, etc.) Vehicle repairs will be considered on a case-by-case basis.

$10,000 maximum per five-year period

You will need to submit:

One estimate on business letterhead
CycleMT Letter of Support Form (click to download)

*Modification work must be under contract within one year of award notification

Type of Request*

Please describe the type of request or need you are submitting.

Completion of Application

To complete the application process, the undersigned does hereby affirm the following:

I am the parent or legal guardian of the applicant or the applicant (if over 18).
I have read the guidelines for financial assistance and eligibility checklist and declare that the information furnished on this application form, including attached sheets, is true and accurate to the best of my knowledge.
I have not requested or received reimbursement for any requests contained in this application. If at a later date I receive funding I will notify CycleMT. Failure to comply may jeopardize future funding requests.

Date:*

Signature of person filling out the application:*

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Relationship to patient:*

Consent and Waiver for CycleMT Funding*

Please read the below consent/participation release statement.

All funding requests are reviewed and voted upon by the CycleMT Distribution Committee which is comprised of Logan Health employees, donors, and community members. When a request is selected to be awarded, Logan Health will purchase or reimburse the expense as stated in the application.

RELEASE:

I, for myself, my heirs, executors and administrators, release and forever discharge Logan Health, Logan Health Medical Center, and their respective agents, employees, representatives, and directors from any and all liability, claims, losses, demands, actions, damages, costs, expenses, judgments and compensation of any kind or nature, arising out of or in any way connected with my participation in the CycleMT Program and awarded funding.

By checking the box you are agreeing to the above statement.

Required Documentation for Each Application Submission:

Previous year's tax statement (first two pages form 1040 form, showing number of dependents and Adjusted Gross Income)
Copy of insurance card(s)
EOB or letter showing insurance will not cover necessary item/service/treatment
Pay stubs from last two pay periods
Letter from parent explaining why child needs assistance
Letter from medical provider explaining why child needs assistance (*medical provider must be a different individual than the provider of non-traditional therapy)

Please Upload All Required Documentation*

Please print and fill out the following documents and upload with your other required documentation before submitting this form:

Authorization of Disclosure of Medical Information
Marketing Release Form

Drag and drop files here or

Send me a copy of my responses

Powered by

Privacy Notice|Report Abuse