Children's Assistive Technology Service (C.A.T.S.)

Equipment Release Form

Please note: The following Equipment Release Form must be signed by the child’s legal guardian for C.A.T.S. to process your order.  If you are requesting equipment on behalf of the legal guardian and you are unable to secure the legal guardian’s online signature, or if you are a school system or healthcare provider requesting equipment for general use, please email Melissa Rose at [email protected] with your order details for further assistance.

Terms and Conditions

 

  1. Equipment Requests

Equipment must be requested by the child’s legal guardian and must include the name and contact information for the referring healthcare provider. Authorized healthcare providers include occupational therapists, physical therapists, and speech and language therapists who are licensed to practice in the Commonwealth of Virginia. All equipment requests must be made on the C.A.T.S. website and must include a completed C.A.T.S. “Equipment Request Form”, this completed and signed C.A.T.S. “Equipment Release” Form”, and a completed and signed C.A.T.S. “Release of Medical Information”. Equipment is provided from available inventory and is first come first served.

  1. How Equipment is Issued
  • A.T.S. sends automated responses by email to equipment requests. If the requester does not reply to C.A.T.S. within 5 days, the equipment will be returned to inventory.
  • The family, caregiver, or designated individual may schedule and pick up adaptive equipment from C.A.T.S. Adaptive equipment is defined as equipment that does not need fitting or customization. Examples include bath chairs, wedges, activity chairs, and medical umbrella strollers.
  • The family, caregiver, or designated individual may schedule and pick up rehab equipment from C.A.T.S. but it requires fitting, customization, or adjustments by the referring healthcare provider. Referral to an Assistive Technology Professional or Durable Medical Equipment vendor will be necessary for power wheelchairs. The fitting or customization must be arranged by the responsible party ordering the equipment. Examples of rehab equipment include manual or power wheelchairs with adaptive seating systems, standers, and gait trainers/walkers.
  • If the equipment is not picked up as scheduled or rescheduled, it will be returned to inventory.
  1. Limitations of Services
  • A.T.S. does not warrant equipment or provide repair services.
  • A.T.S. can provide the family with contact information for local repair service vendors.
  • A child may receive up to 3 pieces of equipment through C.A.T.S. in a calendar year.
  • A.T.S. is unable to provide more than one piece of equipment designed for a specific clinical need, or exchange equipment already provided unless C.A.T.S. establishes a clinical need.
  • Requested equipment must serve a child’s immediate needs. C.A.T.S. does not supply devices for future needs.
  • Equipment is provided from available inventory. C.A.T.S. does not maintain a “wish list” or “wait list” for equipment.
  • A.T.S. does not deliver donated equipment to families. The family must arrange for the pick-up of equipment.
  1. Use of Equipment

All equipment provided by C.A.T.S. is to serve a child’s immediate assistive technology needs. Upon receipt, ownership of the equipment transfers to the child’s legal guardian. However, the sale of equipment provided by C.A.T.S. by the legal guardian is prohibited as a condition of this agreement.

  1. Waiver of Liability
  • All durable medical equipment I receive from C.A.T.S. is non-prescriptive and is free of charge.
  • A.T.S. does not warrant in any way the condition of any equipment I receive from C.A.T.S.
  • I agree to consult the user’s referring healthcare provider that I provided on the “Equipment Request Form” regarding the suitability and the fit of all equipment that I receive from C.A.T.S. before its use and to follow all healthcare provider’s directions for use.
  • I give permission for C.A.T.S. staff to discuss the requested equipment with my child’s referring healthcare provider.
  • I understand that C.A.T.S. does not warrant that any equipment I receive from C.A.T.S. is safe or suitable for any individual.
  • I am responsible for checking to determine if any equipment I receive from C.A.T.S. is covered under the manufacturer’s warranty.
  • A.T.S. is not aware of any Federal Food and Drug Administration (FDA) recall on any equipment that I receive from C.A.T.S., however, I will check to see if the equipment has been recalled by the FDA by going to the website: https://www.fda.gov/medical-devices/medical-device-safety/medical-device-recalls.
  • I am responsible for all repair or maintenance of all equipment that I receive from C.A.T.S.
  • If the equipment I request is part of the C.A.T.S. Communication Loan Library, I understand that this equipment is provided as a loan for up to three months. I agree to return this device to C.A.T.S. in good working condition. If I fail to return the equipment as agreed, I agree to pay for the replacement cost of this device plus shipping and handling.
  • I hereby release and hold harmless C.A.T.S., its personnel, and all persons acting on its behalf from all claims by me or my child, or any person(s) acting on my behalf or my child’s behalf for any loss, personal injury, liability, expense, or damage, including, but not limited to general, specific, incidental, or consequential damages of any kind or nature whatsoever any time, now or in the future arising from the receipt or use of the following equipment provided to me by C.A.T.S.

Equipment Description

 

Order ID: {{order_id}}

Equipment Name(s): {{products_name_in_cart}}

Order Notes: {{customer_note}}


Acknowledgement

 

I have read, understand, and agree to all of the above  “Terms and Conditions “ including all bulleted items in the “Waiver of Liability” section.

Leave this empty:

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Signature Certificate
Document name: Equipment Release Form
lock iconUnique Document ID: e44449da75448b5f31195aec4f9927a622ab2f1b
Timestamp Audit
September 9, 2021 10:03 pm EDTEquipment Release Form Uploaded by CATS Administration - [email protected] IP 2600:8805:1900:b9:8c78:af75:9e16:39ff
August 29, 2022 3:05 pm EDTJohn Naples - [email protected] added by CATS Administration - [email protected] as a CC'd Recipient Ip: 70.160.150.88
August 29, 2022 3:05 pm EDTBeth Beach - [email protected] added by CATS Administration - [email protected] as a CC'd Recipient Ip: 70.160.150.88
August 29, 2022 3:05 pm EDTGardner Umbarger - [email protected] added by CATS Administration - [email protected] as a CC'd Recipient Ip: 70.160.150.88
August 31, 2022 7:22 pm EDTJohn Naples - [email protected] added by CATS Administration - [email protected] as a CC'd Recipient Ip: 2600:8805:1925:9300:d596:bc2f:9b30:cb0b
August 31, 2022 7:22 pm EDTBeth Beach - [email protected] added by CATS Administration - [email protected] as a CC'd Recipient Ip: 2600:8805:1925:9300:d596:bc2f:9b30:cb0b
August 31, 2022 7:22 pm EDTGardner Umbarger - [email protected] added by CATS Administration - [email protected] as a CC'd Recipient Ip: 2600:8805:1925:9300:d596:bc2f:9b30:cb0b