CMEDS Repair Request

CMEDS Repair Request

To be completed by the clients or therapists. All forms are submitted to CMEDSTech@hmebc.com

Client Information

First Name(Required)

Last Name(Required)

Address(Required)

Phone Number(Required)

DOB (MM/DD/YYYY)(Required)

School Name

Therapist Information

First Name(Required)

Last Name(Required)

Phone Number(Required)

Email Address

Does the therapist want to be notified about every repair via email?

Yes

Is the equipment outside of the manufacturer’s warranty and over 2 years old (check with original dealer)? If you selected “No”, please return to the dealer for warranty repair of equipment.

Yes

Was equipment purchased through the At Home Program (not a third party i.e. Variety)? (Only equipment funded by the At Home Program is eligible for repair)

Yes

Is the client eligible for the “At Home Program”? If you selected no, this is a private repair, and the client is not eligible.

Yes

Please note that the following are examples of repair requests that are not eligible for a repair.

Damages caused by the client or third-party damage are not covered (i.e. wheelchair hit by a car, item damages by airline). For those items, the clients/other funders (i.e. ICBC) must cover the repair.
Growth of equipment does not fall under the CMEDS Program, these should be quoted to AHP.
One flat tire repair is covered each year. After one flat tire, it is the client’s responsibility to have it repaired. Clients must put air in tires on their own, this is not a service that is offered.
Batteries have a useful life of 3-5 years. As such, one battery change every 2 years is covered under CMEDS. In the event the batteries become discharged due to lack of charging (i.e. powerchair not used over summer), CMEDS will not cover this and alternative funding will be required.
Damage caused by misuse (i.e. item left out in rain and power joystick is damaged).
Lost items are not covered (i.e. missing leg rests), these should be quoted to the AHP.
Damage caused by fire or floods should be claimed on homeowner’s insurance.
All modifications (i.e. permanent alteration and new parts required) are not covered, these should be quoted to AHP.

Description of equipment (brand name, model, size, serial #, approximate age of equipment, etc.):

Describe how the equipment was damaged or became broken:

Describe issue with equipment:

Photos of the equipment is highly encouraged:

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

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