LMHPCO VA Task Force Tablet Grant Application
The purpose of this form is to provide the opportunity for Hospice & Palliative Care agencies, providing care to Veterans within Louisiana & Mississippi, to receive a tablet to assist with providing telemental health services to those without capability in rural areas. This would allow for agencies who service remote areas without broadband or consistent wireless internet to provide a data connectable tablet to a Veteran family for use to provide trauma care in the field. 

Your agency does not have to be a member of LMHPCO to participate in this process.

If selected, agencies do agree to the conditions outlined below:

1. Agencies must carry a valid data plan within the confines of the area they serve (typical cost, approximately $10.00 monthly, and may be added to your current carrier as long as it provides coverage to your entire service area.)

2. Data must be reported back quarterly to the LMHPCO VA Task Force through a form that will be provided through a link. None of the data provided will require anything related to the direct names or private information of any patient.

3. LMHPCO will download apps to the tablet prior to award and those apps are to be the only ones uploaded to this particular device. LMHPCO reserves the right to inspect equipment at random for compliance.

4. Recipients must maintain active contact information to be updated annually for those interacting with this grant project. Any changes are asked to be reported within 14 days of the change.

5. Recipients must either currently be active or be willing to participate in the We Honor Veterans Program. LMHPCO's VA Task Force will be happy to support any agencies needing assistance getting started.

6. Training will be provided on use of the tablets and proper expectations regarding provision of care for Veterans related to this second phase of the Trauma Informed Care Initiative. If you have questions, please contact veterans@lmhpco.org.
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Agency Name *
Agency Address *
Agency Phone Number *
Agency Fax Number *
Primary Contact Person *
Primary Contact Email *
Primary Contact Discipline *
Secondary Contact Person *
Secondary Contact Email *
Secondary Contact Discipline *
Are you a We Honor Veterans Partner? *
If yes, what Level?
Clear selection
If no, are you willing to become a We Honor Veterans partner?
Clear selection
In what areas does your agency provide services? (Counties, Parishes, Name Major Points of Reference) *
What VA Hospitals or Clinics does your Hospice or Palliative Care Organization have connection to at this time? (Name any you have direct contact or have worked with historically within your service area) *
Please outline any trauma informed care screening process or method of connection with VA Telemental health currently used within your agency. *
I understand by submitting this application my agency agrees to participate within the conditions outlined at the beginning of this process. The agency also agrees to the conditions regarding usage and data requirements for the tablet and upkeeping of data tracking and required training as needed for updates through the initiative. *
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