Apply for Equipment

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Assist ME gives free, gently used medical mobility equipment (like wheelchairs and tub transfer benches) to people in the greater Charlotte, NC region who have low incomes (at or below 200% of Federal Poverty Level) and little or no insurance. Our goal is to help those in need receive the dignity and independence they deserve.

All items are gifted to recipients based on income and medical need.

Online applications are required. However, Assist ME welcomes referrals for all eligible patients, including individuals with disabilities and those facing language barriers to contact our receptionist at 704-659-1123 or email receptionist@assistmenc.com for assistance.

Applicants must assume all responsibility for the equipment, including its proper maintenance and use.

For Individuals Applying for Equipment…read more

For Referral Partners Applying on Behalf of a Patient…read more

Complete the Form Below

Patient Name

Patient's Email

Patient's Phone Number

Employment Status

Other Employment Status

Patient's Street Address

Patient's City

Patient's State

Patient's Zip Code

Patient's Date of Birth

Patient's Gender

Patient's Race

Patient's Household Monthly Income

Number of People Living in Household

Patient's Health Insurance

Patient's Height: Feet

Patient's Height: Inches

Patient's Weight

Patient's Current Location

Other Location

Patient's Discharge Date

Please Select Medical Diagnosis

Briefs, Pullups and/or Pads

Briefs Pullups Pads

Other Equipment Needed

In the last 30 days, how many times have you fallen?

In the last 30 days, how many times have you been admitted to the ER?

What activities will this equipment help Applicant accomplish?

Without this equipment, will you have to change your residence?

Title of Referring Medical Professional

Employer of Referring Medical Professional

Other facility

Name of Referring Medical Professional

Phone Number of Referring Medical Professional

Email of Referring Medical Professional

TERMS of SERVICE: The patient understands that filling out this request does not guarantee they will receive the equipment.

Yes No

TERMS of SERVICE: Assist ME provides all equipment to you in an as-is condition. Assist ME makes no representations or warranties, express or implied, concerning the equipment, including its fitness for a particular purpose or its condition. At the time you pick up the equipment, you will have the opportunity to inspect the equipment’s condition for any defects, issues, and/or problems. YOU AGREE THAT BY ACCEPTING THE EQUIPMENT, YOU ARE ACCEPTING THE EQUIPMENT IN ITS AS-IS CONDITION, INCLUDING ANY FAULTS OR DEFECTS THAT MAY BE PRESENT IN THE EQUIPMENT.

Yes No

TERMS of SERVICE: By accepting the equipment, you further agree to accept all responsibility for the equipment. You agree to waive all claims, liabilities, remedies (at law or in equity), damages, and/or causes of action that you may have against Assist ME, including its past and present owners, members, officers, directors, employees, agents, and/or representatives (“Released Parties”) related to the use of the equipment, including any injuries that may result from the use of the equipment. You further covenant not to sue any of the Released Parties related to the use of the equipment, including any injuries that may result from the use of the equipment.

Yes No

TERMS of SERVICE: The patient gives the Assist ME organization permission to review their medical records and get any information needed from the doctor to justify the need for the requested equipment.

Yes No

TERMS of SERVICE: By accepting the equipment and removing the equipment from the pick-up location, you agree to the above terms and conditions. If you do not accept the above terms and conditions, leave the equipment at the pick-up location.

Yes No

Patient's Signature - The patient should complete their first and last name as their digital signature to certify they understand the above Terms of Service.

Who will pickup Requested Equipment? - If this request is approved and we have the needed medical equipment, you will receive a confirmation email with details on where and when to pick up the equipment. Items are held for 3 days from the time that the confirmation email is sent.

Will you return gently used medical equipment when you no longer need it so that it can be helpful to someone else in need?

Yes No

Our services are charity-based. Would you consider a donation of $5 or more? Donate

Yes No

Call Us

704-659-1123

Email Us

receptionist@assistmenc.com

Visit Us

Atrium Myers Park Clinic

1939 East Boulevard, Charlotte, NC 28207

Finding Us

Pickup Location

Individuals Applying for Equipment

If you do not have an immediate need or you do have insurance coverage, please check with your church, family, friends, Medicare, Medicaid or private insurance providers for assistance before contacting Assist ME. Durable Medical Equipment (DME) providers can help you check insurance and get a doctor’s prescription if needed. This helps us save equipment for those who have no other way to get what they need.

If your insurance cannot help, apply online for gently used equipment from Assist ME.

To qualify, your household income must be below 200% of the Federal Poverty Level. For 2025, this means:

1 person: $31,300/year or less
2 people: $42,300/year or less
3 people: $53,300/year or less

View: 2025 Federal Poverty Guidelines.

If you qualify, you or a representative are responsible for picking up your approved devices, and using and caring for the equipment you receive.

We want your feedback! If you are contacted to participate in a customer satisfaction survey after receiving equipment, please take a few moments to share your experience. Your responses directly demonstrate the impact Assist ME has in our community and play a crucial role in helping us secure the funding needed to advance our mission. Together, we can make a difference for others in need—thank you for lending your voice!

Referral Partners Applying for Patients

Thank you for partnering with Assist ME to help our community get the medically necessary mobility equipment they need.

Accurate Information is Essential:

Please provide complete and accurate patient demographics, including biometrics and up-to-date contact information. This information is critical for timely communication, service, reporting and funding agency requirements.

Online application submission is required. Email submissions will be rejected and result in patient application process delays.
Please confirm that the referral partner’s full name, email address, phone number and employer are valid for contact and reporting purposes.
Collect accurate patient contact details (email, mailing address, and phone number as applicable) for service and patient satisfaction survey needs.
Record the correct contact information for equipment pick-up to avoid pick-up errors.
Referral partners are responsible for sharing pick-up instructions with the equipment pick-up representative.
Please advise Medicaid patients to return Assist ME equipment if Medicaid later provides new equipment. The returned equipment will be used to help another patient without insurance means.

Thank you for your attention to detail and for helping us serve vulnerable members of the Charlotte community more effectively. We appreciate your ongoing support to enhance lives through mobility.

Thank you for connecting with us

Complete the Form Below

Call Us

Email Us

Visit Us

Finding Us

Pickup Location

Individuals Applying for Equipment

Referral Partners Applying for Patients

Assist ME is a non-profit 501c(3) organization
EIN 81-1704351

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