COLORADO TRAUMATIC BRAIN INJURY TRUST FUND

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					       COLORADO TRAUMATIC BRAIN INJURY TRUST FUND
        Important Information for Reapplicants



        Thank you for your interest in the Colorado TBI Trust Fund. Please read the following information
        carefully before completing the application. If you have any questions or need assistance,
        call the Brain Injury Alliance of Colorado at 303.355.9969 or toll-free at 888.331.3311.

       PROGRAM ELIGIBILITY
              To be eligible for the Colorado TBI Trust Fund, you must meet all the following criteria:
                             Have a medically documented traumatic brain injury, resulting in ongoing impairment of
                              cognitive or physical function,
                             Be a resident of Colorado (physically living in the state of Colorado),
                             Be lawfully present in the United States (if 18 years of age or older),
                             Complete and return the application.
              The Colorado TBI Trust Fund Program allows participants to apply for an additional year of
               care coordination.
       PROGRAM REAPPLICATION GUIDELINES

              If there is a waiting list, your name will not be placed on the list until you’ve completed a
               year of care coordination.
              A program participant may receive care coordination and purchased services for one year.
               At the end of a year of services, the participant may re-apply for an additional year of care
               coordination only. No additional funds are available.

       CARE COORDINATION
               Care Coordination is the focus of the Colorado TBI Trust Fund Program.
               A Care Coordinator works with an individual to provide information, identify resources,
                coordinate services, and develop advocacy skills related to their TBI.

       WHERE TO SEND YOUR APPLICATION

                                          Brain Injury Alliance of Colorado
                                          Colorado TBI Trust Fund Program
                                          4200 West Conejos Pl, Ste 524
                                          Denver, Colorado 80204
                                          Fax: 303.355.9968




                                                                                                                       Page 1 of 7
Colorado Traumatic Brain Injury Trust Fund Reapplication (Rev 12/11)
       COLORADO TBI TRUST FUND REAPPLICATION CHECKLIST

       Please use this checklist to make sure you have completed and included all necessary information
       needed to process the application. Please read each carefully:

                                                                       Sections 1 thru 5

                                   Section 1: Applicant Information
                                       All fields are completed.

                                    Section 2: Contact Information (if applicable)
                                       Representative information is completed
                                       Applicable documentation is included:
                                                 o Power of Attorney, or
                                                 o Legal Guardianship

                                    Section 3: Residency Eligibility
                                       Affidavit is signed and dated for applicants age 18 and over.
                                       Clear photocopy of documentation is included for all
                                          applicants 18 years of age or older.

                                   Section 4: Medical Eligibility (if applicable)
                                       If you have suffered another traumatic brain injury since
                                          your first year of services, description of injury is
                                          completed.

                                    Section 5: Authorization
                                       Applicant, Legal Guardian, or POA has signed and dated.


                                                                  Forms A

                                   Form A: Authorization to Release and Share Protected Health Information (PHI)
                                       This is completed when the applicant would like to assign
                                         someone other than, or in addition to themselves to help
                                         with initiating the Trust Fund Program




                                                                                                                   Page 2 of 7
Colorado Traumatic Brain Injury Trust Fund Reapplication (Rev 12/11)
       COLORADO TRAUMATIC BRAIN INJURY TRUST FUND
        Reapplication


SECTION 1: APPLICANT INFORMATION (person applying for services)

Last Name                                                               First                                   Middle Name

Street Address

City                                                                    State                                   ZIP

Home #                                                                  Work #                                County

Cell #                                                       E-mail Address

SSN                                                          DOB                                 Gender:        M            F

                                        African American/Black                           American Indian/Alaskan
Race/Ethnicity                          Asian                                            Caucasian/White
(Optional)                              Hispanic/Latino                                  Pacific Islander
                                        Other: ___________________

Military Status                                                   YES           NO    Specify:             Active Duty           Veteran


                                                                                     If no, would you like
Is English your primary language?                                 YES           NO                                     YES       NO
                                                                                     an interpreter?

If not English, what is your primary
language?

Have you ever been convicted of a
violent crime or felony? (conviction                              YES           NO   If yes, explain:
will not exclude you from program)

Please circle who referred you to the TBI Trust Fund (circle as many that apply):

Primary Care Physician                   Rehab Hospital                         Hospital                       Clinic
Trust Fund Provider                      Community Provider                     Community Non-profit          Brain Injury Alliance of CO
Trust Fund Client                        Denver Options                         Military Agency               Veterans Administration
State Agency                             Educational Facility                   Conference/Event              Support Group
Other                                    Family                                 Friend                         Mild TBI Information Card

Please specify: _______________________________________

                                                                                                                                 Page 3 of 7
Colorado Traumatic Brain Injury Trust Fund Reapplication (Rev 12/11)
SECTION 1: APPLICANT INFORMATION (continued)
Do you have a substance abuse or dependence problem requiring treatment and meet at least one of the
following: age 25 or younger; have used methamphetamines and/or Ecstasy in the past 30 days?
       Yes               No          (If yes, you may be eligible for additional funding.)
Have you applied for the following? (check all that apply)
       Supplemental Security Income (SSI)                                Social Security Disability Insurance Income (SSDI)
Do you receive the following? (check all that apply)
       Supplemental Security Income (SSI)                                Social Security Disability Insurance Income (SSDI)
Do you have medical insurance?                                   Yes           No   Please specify: _______________________
(e.g. Medicaid, Medicare, private)


SECTION 2: REPRESENTATIVE CONTACT INFORMATION (OPTIONAL)

Full Name                                                                               Relationship

Street Address                                                                                            Apt #

City                                                                   State            Zip

Phone #                                                                E-mail Address



Full Name                                                                               Relationship

Street Address                                                                                            Apt #

City                                                                   State            Zip

Phone #                                                                E-Mail Address

                                                      SUPPORTING DOCUMENTATION

Please mark and include one of the following documents to allow Trust Fund staff to communicate
with the representative:
       Power of Attorney
       Legal Guardianship
       Authorization to Release and Share Protected Health Information (Complete Form A)




                                                                                                                      Page 4 of 7
Colorado Traumatic Brain Injury Trust Fund Reapplication (Rev 12/11)
FORM A: AUTHORIZATION TO RELEASE AND SHARE PROTECTED HEALTH INFORMATION (PHI)
I hereby consent to and authorize The Brain Injury Alliance and Colorado Connections, and its
employees, to obtain from and share individually identifiable protected health information with
the individuals/organizations listed below, for the purpose of assisting with and processing the
application and initiating services for the Colorado Traumatic Brain Injury Trust Fund. I understand
that this authorization is voluntary. I understand that if the individuals/organizations authorized by this release
to receive or share my information is not a health plan or health care provider, the released information may be
subject to re-disclosure and no longer protected by federal privacy regulation.

APPLICANT INFORMATION: (person applying for the Colorado TBI Trust Fund Program)

________________________________________                                        ____ / ____ / ____       ____ - ____ - ______
 (Name)                                                                           (Date of Birth)            (SSN)

Individuals/Organizations Authorized to Release & Share Information (Representative Contact, see Section 2, page 4)

__________________________________________________ _____________________________________________________
(Name)                                                                   (Name)

__________________________________________________ _____________________________________________________
(Relationship)                                                           (Relationship)

__________________________________________________ _____________________________________________________
(Contact Information)                                                    (Contact Information)



PURPOSE OF INFORMATION DISCLOSURE:
Initiating Colorado TBI Trust Fund Program

 I understand that the information in my health record may include information relating to sexually transmitted
disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also
include information about behavioral or mental health services, and treatment for alcohol and drug abuse.


 I understand that unless I specify an expiration date or condition, this authorization is valid for the period of
time needed to fulfill its purpose, or for up to one year from date of signature. I also understand that I may
revoke this authorization at any time and that I will be asked to sign the Revocation Section found below. I
further understand that any release of information prior to the rescinded date is legal and binding. This
authorization will expire on ____/____/____ (MM/DD/YY), or otherwise one year from the date this document
is signed. I also understand that I may refuse to sign this authorization and that my services will not be
affected if I do not sign. I further understand that I may request a copy of this signed authorization and that I
may see and copy the information described on this form if I ask for it.

__________________________________________________________________________________________
 (Applicant/Guardian/POA Signature)                                    (Date)                          Witness(if required)
REVOCATION SECTION: (UNLESS YOU WOULD LIKE TO TAKE AWAY ABOVE PRIVILEGES, PLEASE DO NOT SIGN)

I no longer authorize the above named parties to release and share my Protected Health Information.
_______________________________________________                                 ________________     ______________
(Applicant/Guardian/POA Signature)                                           (Date)                 (Time)



                                                                                                                              Page 5 of 7
Colorado Traumatic Brain Injury Trust Fund Reapplication (Rev 12/11)
SECTION 3: RESIDENCY ELIGIBLITY
           LAWFUL PRESENCE IN THE UNITED STATES (for applicants 18 years of age or older)

Effective August 1, 2006, in order to receive benefits provided by the Colorado TBI Trust Fund program, each
eligible applicant 18 years of age or older, must execute an Affidavit stating that he/she is a United States
citizen or legal permanent resident, or is otherwise lawfully present in the United States pursuant to federal law
and provide documentation to verify his/her residency status.

The Affidavit must be executed by each applicant 18 years of age or older:

        I swear or affirm under penalty of perjury under the laws of the state of Colorado that this applicant

 ____________________________________________________________ is (check one):
                                  (name of applicant)


                                a United States citizen;

                                a Permanent Resident in the United States; or

                                lawfully present in the United States pursuant to Federal Law.

I understand that this sworn statement is required by law because I have applied for a public benefit. I
understand that state law requires me to provide proof that I am lawfully present in the United States prior to
receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or
representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second
degree under Colorado Revised Statute 18-8-503 and it shall constitute separate criminal offense each time a
public benefit is fraudulently received.

 _________________________________________________                                          ________________________
  (Applicant/Guardian/POA Signature)                                                         (date)

                                                                       DOCUMENTATION


If 18 years or age or older, you must include a clear photocopy of one of the following documents with your
application:

         Valid Colorado Driver License or Colorado Identification Card issued by CO Department of Revenue; or

         (MILITARY ONLY) Valid Driver License/Identification Card AND military orders stating current stationing in CO; or

         Native American Tribal Document.

Legal aliens must also provide a photocopy of immigration documentation containing your Alien Registration
(A-number) or Admission (I-94) Number.




SECTION 4: MEDICAL ELIGIBLITY


                                                                                                                   Page 6 of 7
Colorado Traumatic Brain Injury Trust Fund Reapplication (Rev 12/11)
Fill out this section ONLY if you have had another injury since your previous year of services.

A traumatic brain injury (TBI) is defined as an injury to the brain caused by an external force. Causes of TBI
include, but are not limited to: falls, motor vehicle-traffic, motorcycle accident, struck by/against, sporting
related injury, assaults, and blast injuries.
Causes of brain injury not included are: anoxia, stroke, aneurysm, congenital abnormality, disease, and surgical
intervention.
                                                                DESCRIPTION OF INJURY
Date(s) of traumatic brain injury: ____ /____ / ____ , ____ / ____ / ____ , ____ / ____ / ____

Cause of traumatic brain injury:                        Fall             Motor Vehicle-traffic         Motorcycle accident            Assault

         Struck by/against                    Sporting related injury                   Blast Injury        Other: ________________

Briefly describe current symptoms:




Describe assistance needed:



SECTION 5: AUTHORIZATION


By signing the application, I swear and attest that the information provided is true and correct to the best of my
knowledge. My signature authorizes the Colorado TBI Trust Fund to:

         Receive reimbursement for funded services if expenses are recovered by a third party, such as lawsuit or
          settlement.
         Be held harmless from any and all claims, disputes, liabilities, or cause of action arising out of the
          agreement to provide assistance, or the providing of assistance by the Colorado TBI Trust Fund.



________________________________                                   ___________________________________                   ___________
(Applicant’s printed name)                                         (Applicant’s signature)                                   (Date)


                                                                                  OR


________________________________                                   ___________________________________                   ___________
(Applicant/Guardian/POA Signature)                                (Applicant/Guardian/POA Signature)                     (Date)



Name of Person Completing Application (If other than applicant)______________________________




                                                                                                                                         Page 7 of 7
  Colorado Traumatic Brain Injury Trust Fund Reapplication (Rev 12/11)

				
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