Application Instructions & Guidelines

Assistance Guidelines

  • All applications must be board approved and grant awarded before prosthesis fabrication.
  • All grants, upon approval, will be supplemented with a grant award letter that will be disbursed to the patient for use at a Texas prosthetic facility of their choice.

Instructions to Apply

  1. This application is an Adobe PDF form. If you don’t have Adobe Acrobat Reader, download and install the free version via the Adobe link to this software provided above.
  2. Download the application pdf. (The download should begin automatically. *Do not* begin filling out the form online if it previews in your browser.)
  3. Open the saved pdf from your computer and fill out each of fields in the 6 pages provided, then save the form.
  4. NOTE: Sign each place required for signature after you are done filling out the entire form. Signing locks the form from any further edits.
  5. The form includes these sections:
    • Checklist – A list of additional documents required with submission.
    • Prosthetic Limb Grant Application
    • HIPAA Medical Information Release Primary Care Physician Form
    • HIPAA Medical Information Release Texas Certified Prosthetist Form
    • Release Form – Photograph and Audio Release Form
  6. Scan the Checklist documents needed as image or PDF formatted files.
  7. Send one email with your filled pdf form and documents as attachments to [email protected]
Download the PDF by clicking the Download Icon
Sample of PDF Application page view in Acrobat Reader.